Provider Demographics
NPI:1821318122
Name:CARPENTER, JACK (PT)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2839 W KENNEWICK AVE # 550
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-2927
Mailing Address - Country:US
Mailing Address - Phone:509-783-8977
Mailing Address - Fax:509-783-6151
Practice Address - Street 1:875 SWIFT BLVD
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3592
Practice Address - Country:US
Practice Address - Phone:509-943-8977
Practice Address - Fax:509-943-6151
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60151910225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist