Provider Demographics
NPI:1790458495
Name:ALBERT, JACK RAYMOND
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:RAYMOND
Last Name:ALBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 PHYSICAL EDUCATION BUILDING
Mailing Address - Street 2:EASTERN WASHINGTON UNIVERSITY
Mailing Address - City:CHENEY
Mailing Address - State:WA
Mailing Address - Zip Code:99004-2476
Mailing Address - Country:US
Mailing Address - Phone:509-359-6399
Mailing Address - Fax:
Practice Address - Street 1:15909 E MARIETTA AVE STE 110
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1888
Practice Address - Country:US
Practice Address - Phone:509-936-7466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT.PT.70004362225100000X
WAATHL.A1.700083372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty