| National Provider Identifier [NPI]: | 1134131055 |
| Last Name Of The Provider | JACKETTA |
| First Name Of The Provider | MICHAEL |
| Middle Initial Of The Provider | G |
| Credentials Of The Provider | MPT, OCS |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 620 WEST CHEYENNE DRIVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | EVANSTON |
| Zip Code Of The Provider | 829305359 |
| State Code Of The Provider | WY |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physical Therapist |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 7 |
| Number Of Services | 2349 |
| Number Of Medicare Beneficiaries | 60 |
| Total Submitted Charge Amount | 117829 |
| Total Medicare Allowed Amount | 63741.73 |
| Total Medicare Payment Amount | 47941.33 |
| Total Medicare Standardized Payment Amount | 29072.19 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 7 |
| Number Of Medical Services | 2349 |
| Number Of Medicare Beneficiaries With Medical Services | 60 |
| Total Medical Submitted Charge Amount | 117829 |
| Total Medical Medicare Allowed Amount | 63741.73 |
| Total Medical Medicare Payment Amount | 47941.33 |
| Total Medical Medicare Standardized Payment Amount | 29072.19 |
| Average Age Of Beneficiaries | 66 |
| Number Of Beneficiaries Age Less65 | 12 |
| Number Of Beneficiaries Age 65 to 74 | 32 |
| Number Of Beneficiaries Age 75 to 84 | 16 |
| Number Of Beneficiaries Age Greater 84 | 0 |
| Number Of Female Beneficiaries | 33 |
| Number Of Male Beneficiaries | 27 |
| Number Of Non Hispanic White Beneficiaries | |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 45 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 15 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 23 |
| Percent Of With Diabetes | 28 |
| Percent Of With Hyperlipidemia | 38 |
| Percent Of With Hypertension | 43 |
| Percent Of With Ischemic Heart Disease | 30 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 65 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.8634 |