Basic Information
| Provider Information | |||||||||
| NPI: | 1922158856 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUEBKE | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | ROGER | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3726 BROADWAY | ||||||||
| Address2: | #104 | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982013787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252524600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10505 19TH AVE SE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982084280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4085700510 | ||||||||
| FaxNumber: | 4089454018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 01/28/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 00002958 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0013LU | 01 | WA | REGENCE | OTHER | 0014LU | 01 | WA | REGENCE | OTHER | 0009LU | 01 | WA | REGENCE | OTHER | 0011LU | 01 | WA | REGENCE | OTHER | 0033LU | 01 | WA | REGENCE | OTHER | 0190810 | 01 | WA | LABOR AND INDUSTRIES | OTHER | 0258807 | 01 | WA | L&I | OTHER | 0258191 | 01 | WA | L&I | OTHER | P00893797 | 01 | WA | RAILROAD MEDICARE | OTHER | 0010LU | 01 | WA | REGENCE | OTHER | 0012LU | 01 | WA | REGENCE | OTHER | 0023LU | 01 | WA | REGENCE | OTHER | 0258768 | 01 | WA | L&I | OTHER | 9141LU | 01 | WA | REGENCE | OTHER |