Provider Demographics
NPI:1447209630
Name:JACKSON, BRANDI L (DPT)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:BRANDI
Other - Middle Name:L
Other - Last Name:KEBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5501 NW 62ND TER STE 102
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64151-2412
Mailing Address - Country:US
Mailing Address - Phone:816-453-4485
Mailing Address - Fax:816-453-4101
Practice Address - Street 1:5501 NW 62ND TER STE 102
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64151-2412
Practice Address - Country:US
Practice Address - Phone:816-453-4485
Practice Address - Fax:816-453-4101
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002030223225100000X
KS11-03206225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKA2868047OtherMEDICARE PTAN
32539062OtherBCBS KC
MOMA4370018OtherMEDICARE PTAN