Provider Demographics
NPI:1356561088
Name:HEBERT, JACKIE (PT)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:HEBERT
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 1:2501 PINE STREET
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77551
Mailing Address - Country:US
Mailing Address - Phone:504-460-5990
Mailing Address - Fax:
Practice Address - Street 1:2228 SEAWALL BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77550
Practice Address - Country:US
Practice Address - Phone:409-762-1004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4634225100000X
CA26272225100000X
TX1164873225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist