Provider Demographics
NPI:1568241834
Name:TALLERICO, JON PATRICK (DPT)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:PATRICK
Last Name:TALLERICO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 S SPARKS AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-2850
Mailing Address - Country:US
Mailing Address - Phone:417-827-9035
Mailing Address - Fax:
Practice Address - Street 1:4411 E SUNSHINE ST STE H
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65809-2907
Practice Address - Country:US
Practice Address - Phone:417-887-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007004680225700000X
MO2023038583225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist