Provider Demographics
NPI:1710995337
Name:SKAGGS, J. MARK (PT, CSCS)
Entity Type:Individual
Prefix:MR
First Name:J.
Middle Name:MARK
Last Name:SKAGGS
Suffix:
Gender:M
Credentials:PT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2662 MCFARLAND RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6806
Mailing Address - Country:US
Mailing Address - Phone:815-227-1700
Mailing Address - Fax:815-227-1744
Practice Address - Street 1:103 N BENTON ST
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:IL
Practice Address - Zip Code:61088-9501
Practice Address - Country:US
Practice Address - Phone:815-335-5223
Practice Address - Fax:815-335-5224
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-005333225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070-005333OtherSTATE LICENSE
P91675Medicare UPIN
L99266Medicare ID - Type Unspecified