MEDICARE: DR. JAKE CONLY PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	10888	LA

General Provider Information

NPI Number	:	1710561915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAKE CONLY PT, DPT

Provider Business Mailing Address
First Line	:	PO BOX 255
Second Line	:
City	:	STONEWALL
State	:	LA
Zip	:	71078-0255
Country	:	US
Telephone Number	:	318-470-3111
Fax Number	:	318-935-9076

Provider Business Practice Location Address
First Line	:	5510 AIRLINE DR STE 104
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-6728
Country	:	US
Telephone Number	:	318-935-9075
Fax Number	:	318-935-9076

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2021
Last Update Date	:	05/12/2021

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