Healthcare Provider Details

I. General information

NPI: 1316864481
Provider Name (Legal Business Name): JOEL RUSSELL DE JONG PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 SW BLUE PKWY
LEES SUMMIT MO
64063-3805
US

IV. Provider business mailing address

806 SW BLUE PKWY
LEES SUMMIT MO
64063-3805
US

V. Phone/Fax

Practice location:
  • Phone: 816-272-1427
  • Fax: 816-600-2602
Mailing address:
  • Phone: 816-272-1427
  • Fax: 816-600-2602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2026028807
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: