Basic Information
| Provider Information | |||||||||
| NPI: | 1639843485 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 HAWTHORNE LN | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461429430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173329861 | ||||||||
| FaxNumber: | 3178934453 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 HAWTHORNE LN | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461429430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173329861 | ||||||||
| FaxNumber: | 3178934453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2021 | ||||||||
| LastUpdateDate: | 08/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 007980 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | IN363 | 05 | KY | MEDICAID |