Provider Demographics
NPI:1881736395
Name:WALDBERG, JEFF (PT, MOMT)
Entity type:Individual
Prefix:MR
First Name:JEFF
Middle Name:
Last Name:WALDBERG
Suffix:
Gender:M
Credentials:PT, MOMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5720 RALSTON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-7844
Mailing Address - Country:US
Mailing Address - Phone:805-804-4168
Mailing Address - Fax:805-830-1177
Practice Address - Street 1:1145 LINDERO CANYON RD STE D7
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91362-5475
Practice Address - Country:US
Practice Address - Phone:818-865-9800
Practice Address - Fax:818-865-9802
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT9727225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT9727OtherSTATE LICENSE