Provider Demographics
NPI:1144315664
Name:KALLBERG, JEFFREY LEONARD (PT)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LEONARD
Last Name:KALLBERG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 W ANNANDALE WAY
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85737-6923
Mailing Address - Country:US
Mailing Address - Phone:952-412-6207
Mailing Address - Fax:952-412-6207
Practice Address - Street 1:843 W ANNANDALE WAY
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85737-6923
Practice Address - Country:US
Practice Address - Phone:952-412-6207
Practice Address - Fax:952-412-6207
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10878PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN160D2KAOtherBLUECROSS BLUESHIELD OF MINNESOTA
MN600088600Medicaid
650001978Medicare PIN