=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730211699
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JIMMIE B BAKER JR. PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2007
-----------------------------------------------------
Last Update Date | 05/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11308 FIRENZE LN
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91326-4194
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-257-1917
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11308 FIRENZE LN
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91326-4194
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-886-8090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT 23997
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------