Provider Demographics
NPI:1013091453
Name:LOMBA, JACK MARCELINO (PT)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:MARCELINO
Last Name:LOMBA
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 1:306 ARROYO MADRONE CT
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648
Mailing Address - Country:US
Mailing Address - Phone:916-543-8506
Mailing Address - Fax:916-543-8506
Practice Address - Street 1:7805 LAGUNE BLVD
Practice Address - Street 2:300
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7952
Practice Address - Country:US
Practice Address - Phone:916-691-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12561225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist