Provider Demographics
NPI:1396484044
Name:PALO, JACK GLEN
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:GLEN
Last Name:PALO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 SINCLAIR RD
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-6590
Mailing Address - Country:US
Mailing Address - Phone:509-306-0698
Mailing Address - Fax:
Practice Address - Street 1:202 SINCLAIR RD
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-6590
Practice Address - Country:US
Practice Address - Phone:509-306-0698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty