Organization
PT COMPANY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. MISTY D JACKSON (BILLING / OFFICE MANAGER)
(731) 288-5056
Entity
Organization
Contact information
Practice address
1400 SHELBY DR, DYERSBURG, TN 38024-3435
(731) 288-5056
(731) 288-5067
Mailing address
1400 SHELBY DR, DYERSBURG, TN 38024-3435
(731) 288-5056
(731) 288-5067
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0446661
—
TN
01
—
4039747
BCBS (GROUP)
TN
Enumeration date
07/13/2006
Last updated
12/18/2013
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