Provider Demographics
NPI:1588933386
Name:MOHR, JACEY LYNNE (PTA)
Entity type:Individual
Prefix:MRS
First Name:JACEY
Middle Name:LYNNE
Last Name:MOHR
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:JACEY
Other - Middle Name:LYNNE
Other - Last Name:WARNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:116 E PRATT
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:64628
Mailing Address - Country:US
Mailing Address - Phone:660-258-7402
Mailing Address - Fax:660-258-2364
Practice Address - Street 1:116 E PRATT
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:MO
Practice Address - Zip Code:64628
Practice Address - Country:US
Practice Address - Phone:660-258-7402
Practice Address - Fax:660-258-2364
Is Sole Proprietor?:No
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008026267225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant