Provider Demographics
NPI:1952484511
Name:JACKSON HOLE PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:JACKSON HOLE PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-734-5292
Mailing Address - Street 1:PO BOX 1828
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-1828
Mailing Address - Country:US
Mailing Address - Phone:307-734-5292
Mailing Address - Fax:307-734-8834
Practice Address - Street 1:4030 LAKE CREEK DR N
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:WY
Practice Address - Zip Code:83014-9689
Practice Address - Country:US
Practice Address - Phone:307-734-5292
Practice Address - Fax:307-734-8834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY05915001OtherBLUE CROSS OF WY