Provider Demographics
NPI:1952301756
Name:JACKSON, DANIEL SHANE (DPT)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:SHANE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 NW 62ND TER STE 102
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64151-2412
Mailing Address - Country:US
Mailing Address - Phone:816-453-4485
Mailing Address - Fax:816-453-4101
Practice Address - Street 1:5501 NW 62ND TER STE 102
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64151-2412
Practice Address - Country:US
Practice Address - Phone:816-453-4485
Practice Address - Fax:816-453-4101
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002029465225100000X
KS11-03205225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS31488029OtherBCBS KANSAS CITY
KS31488029OtherBCBS KANSAS CITY
Q60505Medicare UPIN