Provider Demographics
NPI:1700288578
Name:LAU, JACKIE (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:
Last Name:LAU
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 W VALLEY BLVD
Mailing Address - Street 2:UNIT B
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-2344
Mailing Address - Country:US
Mailing Address - Phone:626-988-6211
Mailing Address - Fax:888-700-7715
Practice Address - Street 1:1731 CAMINO LINDO
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-4131
Practice Address - Country:US
Practice Address - Phone:323-428-8011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-23
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38287225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist