Provider Demographics
NPI:1063607638
Name:JERSAN, KARA A (MSPT)
Entity type:Individual
Prefix:MISS
First Name:KARA
Middle Name:A
Last Name:JERSAN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 S EUCLID
Mailing Address - Street 2:SUITE G
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108
Mailing Address - Country:US
Mailing Address - Phone:314-276-1789
Mailing Address - Fax:314-972-0472
Practice Address - Street 1:10 S EUCLID
Practice Address - Street 2:SUITE G
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108
Practice Address - Country:US
Practice Address - Phone:314-276-1789
Practice Address - Fax:314-972-0472
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO118023225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO484888227Medicaid