MEDICARE: MRS. ALICIA JACKSON JUCKETT LPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	6841	TN

General Provider Information

NPI Number	:	1841295359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ALICIA JACKSON JUCKETT LPT

Provider Business Mailing Address
First Line	:	8110 CORDOVA ROAD
Second Line	:	STE 107
City	:	CORDOVA
State	:	TN
Zip	:	38016-0517
Country	:	US
Telephone Number	:	901-756-1650
Fax Number	:	901-756-1396

Provider Business Practice Location Address
First Line	:	8110 CORDOVA RD
Second Line	:	STE 107
City	:	CORDOVA
State	:	TN
Zip	:	38016-0520
Country	:	US
Telephone Number	:	901-756-1650
Fax Number	:	901-756-1396

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	09/16/2008

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