Healthcare Provider Details

I. General information

NPI: 1053322081
Provider Name (Legal Business Name): JEREMY RYAN SKEEN P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N MAIN ST STE 1
MOUNTAIN GROVE MO
65711-1025
US

IV. Provider business mailing address

2596 PINE RIDGE LANE
MOUNTAIN GROVE MO
65711
US

V. Phone/Fax

Practice location:
  • Phone: 417-926-5699
  • Fax: 417-926-5703
Mailing address:
  • Phone: 417-962-0034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2001017159
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: