Provider Demographics
NPI:1558567958
Name:KOSSOW, JACQUELINE (PT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:KOSSOW
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 1:6501 BRIXTON RD
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1102
Mailing Address - Country:US
Mailing Address - Phone:419-708-6295
Mailing Address - Fax:
Practice Address - Street 1:555 ANTHONY WAYNE TRL
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43566-1516
Practice Address - Country:US
Practice Address - Phone:419-878-3901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist