Provider Demographics
NPI:1295940369
Name:BARRACK, JEANETTE T (PT)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:T
Last Name:BARRACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5360 JACKSON DR STE 110
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3012
Mailing Address - Country:US
Mailing Address - Phone:619-667-7000
Mailing Address - Fax:619-667-7000
Practice Address - Street 1:5360 JACKSON DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-6002
Practice Address - Country:US
Practice Address - Phone:616-667-7000
Practice Address - Fax:619-667-4315
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11265225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1023103330OtherNPI
CAPT11265OtherPT LICENSE