Organization
WYOMING SPECIALIZED PHYSICAL THERAPY INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL G JACKETTA DPT OCS (OWNER)
(307) 789-8860
Entity
Organization
Contact information
Practice address
620 W CHEYENNE DR., EVANSTON, WY 82930-5505
(307) 789-8860
(307) 789-8394
Mailing address
620 W CHEYENNE DR., EVANSTON, WY 82930-5505
(307) 789-8860
(307) 789-8394
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
—
—
2251X0800X
Orthopedic Physical Therapist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
118279000
—
WY
Enumeration date
08/12/2006
Last updated
11/01/2021
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