Provider Demographics
NPI:1770516502
Name:KOURY, JACKI L (PT)
Entity type:Individual
Prefix:
First Name:JACKI
Middle Name:L
Last Name:KOURY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JACKI
Other - Middle Name:L
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1775 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-1926
Mailing Address - Country:US
Mailing Address - Phone:719-477-6870
Mailing Address - Fax:719-477-1483
Practice Address - Street 1:1775 S 8TH ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-1926
Practice Address - Country:US
Practice Address - Phone:719-477-6870
Practice Address - Fax:719-477-1483
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6673225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO551698Medicare ID - Type Unspecified