Provider Demographics
NPI:1013055755
Name:BOURLA, JACK MARTIN (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:MARTIN
Last Name:BOURLA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:499 SEAPORT CT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-2783
Mailing Address - Country:US
Mailing Address - Phone:650-365-1473
Mailing Address - Fax:650-365-1474
Practice Address - Street 1:499 SEAPORT CT
Practice Address - Street 2:SUITE 101
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-2783
Practice Address - Country:US
Practice Address - Phone:650-365-1473
Practice Address - Fax:650-365-1474
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25312111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU95781Medicare UPIN