Provider Demographics
NPI:1720891443
Name:IBARRA, ZACHERY JORDAN (PT)
Entity type:Individual
Prefix:
First Name:ZACHERY
Middle Name:JORDAN
Last Name:IBARRA
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 1:2000 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-4200
Mailing Address - Country:US
Mailing Address - Phone:512-759-6438
Mailing Address - Fax:
Practice Address - Street 1:2000 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-4200
Practice Address - Country:US
Practice Address - Phone:512-759-6438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-28
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1209009225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist