Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 2001009684 | MO |
N | 2251S0007X | Physical Therapist - Sports | 2003004222 | MO |
NPI | 1548235542 |
---|---|
Provider Name | Mr. Jeffrey Thomas Gillum |
First Address | Imperial, MO 63052-1573 |
Second Address | Farmington, MO 63640-2932 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/02/2006 |
Last Update Date | 08/07/2007 |