Provider Demographics
NPI:1033468301
Name:ROSENTHAL, JACQUELINE KAYE (MPT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:KAYE
Last Name:ROSENTHAL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:SELSOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 WINTER RIVER CT
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-8009
Mailing Address - Country:US
Mailing Address - Phone:314-974-5018
Mailing Address - Fax:
Practice Address - Street 1:3488 JEFFCO BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-6015
Practice Address - Country:US
Practice Address - Phone:636-464-5439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-02
Last Update Date:2012-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20090244282251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics