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General NPI Number Information
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NPI Number | 1790458495
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Entity Type | Individual
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Provider Name | JACK RAYMOND ALBERT
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Gender | Male
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Dates
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Enumeration Date | 07/28/2021
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Last Update Date | 06/05/2025
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Provider Practice Location Address
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Address Line | 15909 E MARIETTA AVE STE 110
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City | SPOKANE VALLEY
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State | WA
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Zip | 99216-1888
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Country | US
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Telephone | 509-936-7466
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Fax |
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Provider Business Mailing Address
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Address Line | 207 PHYSICAL EDUCATION BUILDING EASTERN WASHINGTON UNIVERSITY
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City | CHENEY
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State | WA
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Zip | 99004-2476
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Country | US
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Telephone | 509-359-6399
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT.PT.70004362
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | ATHL.A1.70008337
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License Number State | WA
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