Provider Demographics
NPI:1154719755
Name:VOGAN, JACKIE (PTA)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:VOGAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:LYNN
Other - Last Name:BOYD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:209 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:RUSHVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64484-9531
Mailing Address - Country:US
Mailing Address - Phone:816-261-2414
Mailing Address - Fax:
Practice Address - Street 1:209 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:MO
Practice Address - Zip Code:64484-9531
Practice Address - Country:US
Practice Address - Phone:816-261-2414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-02607225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant