Healthcare Provider Details

I. General information

NPI: 1225792013
Provider Name (Legal Business Name): JACQUELINE LEE BARLOW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11126 PINEDALE DR
ROLLA MO
65401-7912
US

IV. Provider business mailing address

11126 PINEDALE DR
ROLLA MO
65401-7912
US

V. Phone/Fax

Practice location:
  • Phone: 314-619-1206
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1999140711
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: