Healthcare Provider Details

I. General information

NPI: 1851122998
Provider Name (Legal Business Name): JACK THOMAS KOBYLKA PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2024
Last Update Date: 08/10/2024
Certification Date: 08/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 NW MARKET ST STE B
SEATTLE WA
98107-5815
US

IV. Provider business mailing address

1613 MCKINLEY RD
NAPA CA
94558-2009
US

V. Phone/Fax

Practice location:
  • Phone: 206-706-0063
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT61574051
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: