Provider Demographics
NPI:1780020222
Name:CALVERT, JACK C (LMP)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:C
Last Name:CALVERT
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 TIERRA VIDA LN
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-5085
Mailing Address - Country:US
Mailing Address - Phone:509-855-3869
Mailing Address - Fax:
Practice Address - Street 1:155 N ELY ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-2941
Practice Address - Country:US
Practice Address - Phone:509-735-6479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-10
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60337092225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist