Provider Demographics
NPI:1366198731
Name:MOSS, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:MOSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W 151ST STREET
Mailing Address - Street 2:SUITE 102
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:W 151ST STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66223
Practice Address - Country:US
Practice Address - Phone:913-897-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-06952225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist