Provider Demographics
NPI:1780895771
Name:BENNETT, JACK (PT)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11709 OLD BALLAS RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7029
Mailing Address - Country:US
Mailing Address - Phone:314-991-0480
Mailing Address - Fax:317-991-0487
Practice Address - Street 1:11709 OLD BALLAS RD
Practice Address - Street 2:SUITE 205
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7029
Practice Address - Country:US
Practice Address - Phone:314-991-0480
Practice Address - Fax:317-991-0487
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1364225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist