Provider Demographics
NPI:1265519151
Name:JACOB'S LADDER PEDIATRIC REHAB CENTER
Entity type:Organization
Organization Name:JACOB'S LADDER PEDIATRIC REHAB CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ADMIN OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-250-3203
Mailing Address - Street 1:1595 S CALUMET RD STE 3
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-2389
Mailing Address - Country:US
Mailing Address - Phone:219-764-4888
Mailing Address - Fax:219-764-4805
Practice Address - Street 1:1595 S CALUMET RD STE 3
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-2389
Practice Address - Country:US
Practice Address - Phone:219-763-6858
Practice Address - Fax:219-763-4858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200196020AMedicaid