Provider Demographics
NPI:1073613329
Name:IBBETSON, JACKI (PT)
Entity Type:Individual
Prefix:
First Name:JACKI
Middle Name:
Last Name:IBBETSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10701 NALL AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1363
Mailing Address - Country:US
Mailing Address - Phone:913-663-2555
Mailing Address - Fax:
Practice Address - Street 1:1000 CARONDELET DR
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-4673
Practice Address - Country:US
Practice Address - Phone:816-943-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-02544225100000X
MO2008007265225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist