Provider Demographics
NPI:1134131055
Name:JACKETTA, MICHAEL GENE (MPT, OCS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GENE
Last Name:JACKETTA
Suffix:
Gender:M
Credentials:MPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 WEST CHEYENNE DRIVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-5359
Mailing Address - Country:US
Mailing Address - Phone:307-789-8860
Mailing Address - Fax:307-789-8394
Practice Address - Street 1:620 WEST CHEYENNE DRIVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5359
Practice Address - Country:US
Practice Address - Phone:307-789-8860
Practice Address - Fax:307-789-8394
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY117012100 118279000Medicaid
WY117012100 118279000Medicaid