Provider Demographics
NPI:1306935465
Name:EMERY, JACK L (PT)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:L
Last Name:EMERY
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 1:14820 ECHO RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-9633
Mailing Address - Country:US
Mailing Address - Phone:530-265-2741
Mailing Address - Fax:
Practice Address - Street 1:1020D MCCOURTNEY RD
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95949-7400
Practice Address - Country:US
Practice Address - Phone:530-274-8720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16709261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT167090Medicare ID - Type Unspecified