Individual
JACK BENNETT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
11709 OLD BALLAS RD, SUITE 205, SAINT LOUIS, MO 63141-7029
(314) 991-0480
(317) 991-0487
Mailing address
11709 OLD BALLAS RD, SUITE 205, SAINT LOUIS, MO 63141-7029
(314) 991-0480
(317) 991-0487
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
R1364
MO
Other
Enumeration date
05/24/2007
Last updated
07/08/2007
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