Healthcare Provider Details

I. General information

NPI: 1548235542
Provider Name (Legal Business Name): JEFFREY THOMAS GILLUM MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JEFFERSON BARRACKS DR
SAINT LOUIS MO
63125-4181
US

IV. Provider business mailing address

1001 SABLE LN
ARNOLD MO
63010-2588
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax:
Mailing address:
  • Phone: 314-652-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2001009684
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number2003004222
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2251E1200X
TaxonomyErgonomics Physical Therapist
License Number2001009684
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: