Basic Information
| Provider Information | |||||||||
| NPI: | 1477224293 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORES | ||||||||
| FirstName: | JACKSON | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | PT, DPT, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10730 NALL AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662111285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135881227 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10730 NALL AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662111285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135881227 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2021 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2021032083 | MO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 11006773 | KS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.