Provider Demographics
NPI:1235444100
Name:EATON, JACQUELYN L (PTA)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:L
Last Name:EATON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:L
Other - Last Name:EATON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA / MCST
Mailing Address - Street 1:600 PERRY ST
Mailing Address - Street 2:
Mailing Address - City:ROSSVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:66533-9784
Mailing Address - Country:US
Mailing Address - Phone:785-584-6968
Mailing Address - Fax:785-584-6005
Practice Address - Street 1:600 PERRY ST
Practice Address - Street 2:
Practice Address - City:ROSSVILLE
Practice Address - State:KS
Practice Address - Zip Code:66533-9784
Practice Address - Country:US
Practice Address - Phone:785-584-6968
Practice Address - Fax:785-584-6005
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-01828225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant