Basic Information
| Provider Information | |||||||||
| NPI: | 1396949806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACQUINOT | ||||||||
| FirstName: | MARLA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BENNETT | ||||||||
| OtherFirstName: | MARLA | ||||||||
| OtherMiddleName: | J | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5799 BROADMOOR ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MISSION | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662022427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133845600 | ||||||||
| FaxNumber: | 9133840719 | ||||||||
| Practice Location | |||||||||
| Address1: | 5799 BROADMOOR ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MISSION | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662022427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133845600 | ||||||||
| FaxNumber: | 9133840719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 01/08/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2000167616 | MO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 11-03521 | KS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | T66000002 | 01 | KS | MEDICARE PTAN | OTHER | T66A00003 | 01 | MO | MEDICARE PTAN | OTHER |