Healthcare Provider Details

I. General information

NPI: 1649495813
Provider Name (Legal Business Name): GINNY ROESTEL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GINNY ROESTEL PTA

II. Dates (important events)

Enumeration Date: 04/14/2007
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 LAS BRISAS CT
JEFFERSON CITY MO
65101-5602
US

IV. Provider business mailing address

1010 LAS BRISAS CT
JEFFERSON CITY MO
65101-5602
US

V. Phone/Fax

Practice location:
  • Phone: 217-821-5733
  • Fax:
Mailing address:
  • Phone: 217-821-5733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160-003853
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: