Healthcare Provider Details

I. General information

NPI: 1982027520
Provider Name (Legal Business Name): JUMPSTART PT 4 KIDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2014
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 KNOLLSHIRE WAY
DARDENNE PRAIRIE MO
63368-8379
US

IV. Provider business mailing address

643 KNOLLSHIRE WAY
DARDENNE PRAIRIE MO
63368-8379
US

V. Phone/Fax

Practice location:
  • Phone: 636-541-2398
  • Fax: 636-265-2158
Mailing address:
  • Phone: 636-541-2398
  • Fax: 636-265-2158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number109323
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number115066
License Number StateMO

VIII. Authorized Official

Name: JENNIFER BECKER
Title or Position: PTA
Credential:
Phone: 636-541-2398