Provider Demographics
NPI:1720265739
Name:JACKSON PREFERRED REHAB LLC
Entity Type:Organization
Organization Name:JACKSON PREFERRED REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KARTHYAYANI
Authorized Official - Middle Name:
Authorized Official - Last Name:KUNCHAPPA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:866-568-3100
Mailing Address - Street 1:119 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:MI
Mailing Address - Zip Code:49245-1023
Mailing Address - Country:US
Mailing Address - Phone:866-568-3100
Mailing Address - Fax:517-568-3133
Practice Address - Street 1:119 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:MI
Practice Address - Zip Code:49245-1023
Practice Address - Country:US
Practice Address - Phone:866-568-3100
Practice Address - Fax:517-568-3133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKK007396225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650C807050OtherBLUE CROSS
MIKK007396OtherLIC NUMBER
MI650C807050OtherBLUE CROSS
MI650C807050OtherBLUE CROSS