Provider Demographics
NPI:1154339281
Name:BERNACKI, TIMOTHY JASON (PT)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JASON
Last Name:BERNACKI
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 1:4284 TRAIL BOSS DR STE 130
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-7521
Mailing Address - Country:US
Mailing Address - Phone:303-663-8086
Mailing Address - Fax:303-663-8289
Practice Address - Street 1:4284 TRAIL BOSS DR STE 130
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-7521
Practice Address - Country:US
Practice Address - Phone:303-663-8086
Practice Address - Fax:303-663-8289
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8065225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV00340278Medicaid
NV105626Medicare PIN