Provider Demographics
NPI:1992845192
Name:TEAGUE, JACK URIAH (PT)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:URIAH
Last Name:TEAGUE
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 1:9209 126TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-5901
Mailing Address - Country:US
Mailing Address - Phone:425-827-4758
Mailing Address - Fax:
Practice Address - Street 1:18107 BOTHELL WAY NE
Practice Address - Street 2:SUITE 106
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-1900
Practice Address - Country:US
Practice Address - Phone:425-487-3142
Practice Address - Fax:425-487-8785
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00000652225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB10945Medicare PIN
WAAB 10945Medicare ID - Type Unspecified