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General NPI Number Information
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NPI Number | 1174650659
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Entity Type | Individual
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Provider Name | JEREMY STILLWELL PT
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Gender | Male
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Dates
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Enumeration Date | 02/28/2007
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Last Update Date | 09/28/2010
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Provider Practice Location Address
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Address Line | 217 SAM HOUSTON JONES PKWY STE 103
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City | LAKE CHARLES
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State | LA
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Zip | 70611-5644
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Country | US
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Telephone | 337-217-0997
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Fax | 337-217-0998
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Provider Business Mailing Address
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Address Line | 2100 OAK PARK BLVD
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City | LAKE CHARLES
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State | LA
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Zip | 70601-7864
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Country | US
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Telephone | 337-310-5116
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Fax | 337-310-5118
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 02441
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License Number State | LA
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