Healthcare Provider Details

I. General information

NPI: 1861274284
Provider Name (Legal Business Name): JDV PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2023
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5850 NEOSHO ST
SAINT LOUIS MO
63109-3118
US

IV. Provider business mailing address

5850 NEOSHO ST
SAINT LOUIS MO
63109-3118
US

V. Phone/Fax

Practice location:
  • Phone: 618-792-9734
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRITTNE FULLER
Title or Position: OFFICE MANAGER
Credential:
Phone: 618-978-6432