Provider Demographics
NPI:1922158856
Name:LUEBKE, JON ROGER (PT)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:ROGER
Last Name:LUEBKE
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 1:3726 BROADWAY
Mailing Address - Street 2:#104
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3787
Mailing Address - Country:US
Mailing Address - Phone:425-252-4600
Mailing Address - Fax:
Practice Address - Street 1:10505 19TH AVE SE
Practice Address - Street 2:SUITE B
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-4280
Practice Address - Country:US
Practice Address - Phone:408-570-0510
Practice Address - Fax:408-945-4018
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT 00002958225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0013LUOtherREGENCE
WA0014LUOtherREGENCE
WA0009LUOtherREGENCE
WA0011LUOtherREGENCE
WA0033LUOtherREGENCE
WA0190810OtherLABOR AND INDUSTRIES
WA0258807OtherL&I
WA0258191OtherL&I
WAP00893797OtherRAILROAD MEDICARE
WA0010LUOtherREGENCE
WA0012LUOtherREGENCE
WA0023LUOtherREGENCE
WA0258768OtherL&I
WA9141LUOtherREGENCE
WAG8888267Medicare PIN
WA0011LUOtherREGENCE
WAP00893797OtherRAILROAD MEDICARE
WA9141LUOtherREGENCE