Individual
MICHAEL GENE JACKETTA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MPT, OCS
Contact information
Practice address
620 WEST CHEYENNE DRIVE, EVANSTON, WY 82930-5359
(307) 789-8860
(307) 789-8394
Mailing address
620 WEST CHEYENNE DRIVE, EVANSTON, WY 82930-5359
(307) 789-8860
(307) 789-8394
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
840
WY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
117012100 118279000
—
WY
Enumeration date
08/12/2006
Last updated
07/08/2007
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