Healthcare Provider Details

I. General information

NPI: 1174650659
Provider Name (Legal Business Name): JEREMY STILLWELL PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 09/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 SAM HOUSTON JONES PKWY STE 103
LAKE CHARLES LA
70611-5644
US

IV. Provider business mailing address

2100 OAK PARK BLVD
LAKE CHARLES LA
70601-7864
US

V. Phone/Fax

Practice location:
  • Phone: 337-217-0997
  • Fax: 337-217-0998
Mailing address:
  • Phone: 337-310-5116
  • Fax: 337-310-5118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number02441
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: