Provider Demographics
NPI:1669029609
Name:LITTLE, JACK JOEL
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:JOEL
Last Name:LITTLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5445 DTC PKWY STE 1130
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-3038
Mailing Address - Country:US
Mailing Address - Phone:720-749-5599
Mailing Address - Fax:720-925-5897
Practice Address - Street 1:9000 W THUNDERBIRD RD # 205
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4451
Practice Address - Country:US
Practice Address - Phone:602-491-1948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30858208100000X
AZLPT-30858225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation