Healthcare Provider Details

I. General information

NPI: 1922886100
Provider Name (Legal Business Name): JAMES WACKERLY PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2023
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3780 MEDINA RD STE 300
MEDINA OH
44256-9312
US

IV. Provider business mailing address

1217 HATHAWAY AVE
LAKEWOOD OH
44107-2721
US

V. Phone/Fax

Practice location:
  • Phone: 234-867-7749
  • Fax: 234-312-2456
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: