Provider Demographics
NPI:1891702668
Name:CABALKA, JACQUELINE (PT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:CABALKA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 PARKVIEW N
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-3847
Mailing Address - Country:US
Mailing Address - Phone:805-710-4158
Mailing Address - Fax:
Practice Address - Street 1:1545 HIGUERA ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2917
Practice Address - Country:US
Practice Address - Phone:805-543-5633
Practice Address - Fax:805-543-5990
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20625225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT20625AMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER