Provider Demographics
NPI:1982027520
Name:JUMPSTART PT 4 KIDS LLC
Entity Type:Organization
Organization Name:JUMPSTART PT 4 KIDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PTA
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-541-2398
Mailing Address - Street 1:643 KNOLLSHIRE WAY
Mailing Address - Street 2:
Mailing Address - City:DARDENNE PRAIRIE
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8379
Mailing Address - Country:US
Mailing Address - Phone:636-541-2398
Mailing Address - Fax:636-265-2158
Practice Address - Street 1:643 KNOLLSHIRE WAY
Practice Address - Street 2:
Practice Address - City:DARDENNE PRAIRIE
Practice Address - State:MO
Practice Address - Zip Code:63368-8379
Practice Address - Country:US
Practice Address - Phone:636-541-2398
Practice Address - Fax:636-265-2158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109323225100000X
MO115066225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty