Provider Demographics
NPI:1295931236
Name:BERKE, JACQUELINE LYNN
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LYNN
Last Name:BERKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 TRIANGLE ST
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-3249
Mailing Address - Country:US
Mailing Address - Phone:805-382-3074
Mailing Address - Fax:805-382-3077
Practice Address - Street 1:1751 LOMBARD ST
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-8266
Practice Address - Country:US
Practice Address - Phone:805-382-3074
Practice Address - Fax:805-382-3077
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT9177225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist