Provider Demographics
NPI:1306049887
Name:MCCLAIN, KRISTA MARIE (PT)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:MARIE
Last Name:MCCLAIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:MARIE
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3630 N WAYNE AVE # 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3714
Mailing Address - Country:US
Mailing Address - Phone:312-835-7490
Mailing Address - Fax:
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:206-341-0461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00010434225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist