Provider Demographics
NPI:1508952649
Name:JACKSON CO PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:JACKSON CO PHYSICAL THERAPY INC
Other - Org Name:JCPT
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF PHYSICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:JACINTO
Authorized Official - Last Name:ODANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:304-372-7479
Mailing Address - Street 1:344 B S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25271-1512
Mailing Address - Country:US
Mailing Address - Phone:304-372-7479
Mailing Address - Fax:304-372-7483
Practice Address - Street 1:344 B S CHURCH ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:WV
Practice Address - Zip Code:25271-1512
Practice Address - Country:US
Practice Address - Phone:304-372-7479
Practice Address - Fax:304-372-7483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV 727225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9302111Medicare PIN