Healthcare Provider Details

I. General information

NPI: 1306935465
Provider Name (Legal Business Name): JACK L EMERY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020D MCCOURTNEY RD
GRASS VALLEY CA
95949-7400
US

IV. Provider business mailing address

14820 ECHO RIDGE DR
NEVADA CITY CA
95959-9633
US

V. Phone/Fax

Practice location:
  • Phone: 530-274-8720
  • Fax:
Mailing address:
  • Phone: 530-265-2741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number16709
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: