Provider Demographics
NPI:1750633665
Name:PICKETT, JAMES WILLIAM JR (PTA)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:WILLIAM
Last Name:PICKETT
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 FROSTY LN
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46012-9631
Mailing Address - Country:US
Mailing Address - Phone:765-461-5192
Mailing Address - Fax:
Practice Address - Street 1:101 W SOUTHWAY BLVD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3653
Practice Address - Country:US
Practice Address - Phone:765-453-8855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004485A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant