Provider Demographics
NPI:1881828762
Name:DILLENDER, JACK PERCY II (LMT)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:PERCY
Last Name:DILLENDER
Suffix:II
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 MANOR DR
Mailing Address - Street 2:2101CORONA ROAD #201
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-1737
Mailing Address - Country:US
Mailing Address - Phone:573-814-1418
Mailing Address - Fax:
Practice Address - Street 1:709 MANOR DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-1737
Practice Address - Country:US
Practice Address - Phone:573-814-1418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-07
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002028196225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2002028196OtherMASSAGE THERAPY