Healthcare Provider Details

I. General information

NPI: 1558742981
Provider Name (Legal Business Name): BACK COUNTRY PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1262 W 5TH ST
SHERIDAN WY
82801-2702
US

IV. Provider business mailing address

51 COFFEEN AVE. STE 101 PMB 286
SHERIDAN WY
82801-7004
US

V. Phone/Fax

Practice location:
  • Phone: 307-336-7774
  • Fax: 307-202-4643
Mailing address:
  • Phone: 307-336-7774
  • Fax: 307-202-4643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-1552
License Number StateWY

VIII. Authorized Official

Name: DR. BRETT A JENKS
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: PT, DPT, CERT. MDT
Phone: 307-336-7774