Provider Demographics
NPI:1609998954
Name:JACKSON'S PREFERRED REHAB
Entity Type:Organization
Organization Name:JACKSON'S PREFERRED REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARTHYAYANI
Authorized Official - Middle Name:
Authorized Official - Last Name:KUNCHAPPA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:517-745-3161
Mailing Address - Street 1:110 E. MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:GRASS LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49240
Mailing Address - Country:US
Mailing Address - Phone:517-522-4828
Mailing Address - Fax:
Practice Address - Street 1:110 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRASS LAKE
Practice Address - State:MI
Practice Address - Zip Code:49240-9680
Practice Address - Country:US
Practice Address - Phone:517-745-3161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007396225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI65C807050OtherBLUE CROSS
MI0N77640Medicare PIN