Healthcare Provider Details

I. General information

NPI: 1831162320
Provider Name (Legal Business Name): JACK HOLLIDAY BROWNE OTR, CHT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34730 BOB WILSON DR PHYSICAL AND OCCUPATIONAL THERAPY STE 102
SAN DIEGO CA
92134-3098
US

IV. Provider business mailing address

3290 CAMINITO EASTBLUFF UNIT 124
LA JOLLA CA
92037-2878
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-7135
  • Fax:
Mailing address:
  • Phone: 619-532-7135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number6463
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: