Healthcare Provider Details

I. General information

NPI: 1013394907
Provider Name (Legal Business Name): JARED TRENT LANDRY D.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2015
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 OAK PARK BLVD
LAKE CHARLES LA
70601-7864
US

IV. Provider business mailing address

PO BOX 2188
LAKE CHARLES LA
70602-2188
US

V. Phone/Fax

Practice location:
  • Phone: 337-310-5116
  • Fax:
Mailing address:
  • Phone: 337-494-7546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: