MEDICARE: JACKSON PHYSICAL THERAPY & REHABILITATION, INC.

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	00932	MO

General Provider Information

NPI Number	:	1881705721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON PHYSICAL THERAPY & REHABILITATION, INC.

Provider Business Mailing Address
First Line	:	310 E MAIN ST
Second Line	:
City	:	JACKSON
State	:	MO
Zip	:	63755-1456
Country	:	US
Telephone Number	:	573-243-1001
Fax Number	:	573-243-1401

Provider Business Practice Location Address
First Line	:	310 E MAIN ST
Second Line	:
City	:	JACKSON
State	:	MO
Zip	:	63755-1456
Country	:	US
Telephone Number	:	573-243-1001
Fax Number	:	573-243-1401

Authorized Official
Title or Position	:	OWNER/P.T.
Name	:	MRS. VICKI LYNN KELLER
Credential	:	P.T.
Telephone Number	:	573-243-1001

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	08/22/2020

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