Provider Demographics
NPI:1972902799
Name:BALZER, JACKIE (DPT)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:
Last Name:BALZER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 ELM ST
Mailing Address - Street 2:APT 405C
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-8625
Mailing Address - Country:US
Mailing Address - Phone:520-360-2500
Mailing Address - Fax:
Practice Address - Street 1:1260 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-4806
Practice Address - Country:US
Practice Address - Phone:203-630-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT010262225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD100085342OtherMEDICARE PTAN