Provider Demographics
NPI:1417286634
Name:BALL, JACQUELYN N (PT)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:N
Last Name:BALL
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 1:324 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-2306
Mailing Address - Country:US
Mailing Address - Phone:636-239-7848
Mailing Address - Fax:
Practice Address - Street 1:324 W 5TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-2306
Practice Address - Country:US
Practice Address - Phone:636-239-7848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-17
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT25053225100000X
MO2009019552225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT25053OtherLICENSE NUMBER
FLPT25053OtherLICENSE NUMBER