Provider Demographics
NPI:1932118866
Name:JASPER PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:JASPER PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:T
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-692-9080
Mailing Address - Street 1:620 J L WHITE DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-4896
Mailing Address - Country:US
Mailing Address - Phone:706-692-9080
Mailing Address - Fax:706-692-1199
Practice Address - Street 1:620 J L WHITE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-4896
Practice Address - Country:US
Practice Address - Phone:706-692-9080
Practice Address - Fax:706-692-1199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3867Medicare ID - Type UnspecifiedGROUP NUMBER FOR PRACTICE