Provider Demographics
NPI:1053816983
Name:WRIGHT, JEFFREY
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-813-2962
Mailing Address - Fax:318-813-2981
Practice Address - Street 1:1450 CLAIBORNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4204
Practice Address - Country:US
Practice Address - Phone:318-813-2970
Practice Address - Fax:318-813-2975
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA4669225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1174173Medicaid