Provider Demographics
NPI:1881705721
Name:JACKSON PHYSICAL THERAPY & REHABILITATION, INC.
Entity type:Organization
Organization Name:JACKSON PHYSICAL THERAPY & REHABILITATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/P.T.
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:573-243-1001
Mailing Address - Street 1:310 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-1456
Mailing Address - Country:US
Mailing Address - Phone:573-243-1001
Mailing Address - Fax:573-243-1401
Practice Address - Street 1:310 E MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-1456
Practice Address - Country:US
Practice Address - Phone:573-243-1001
Practice Address - Fax:573-243-1401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00932225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty