Provider Demographics
NPI:1154645372
Name:SUTTON, JEREMIAH CHRISTOPHER (PT)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:CHRISTOPHER
Last Name:SUTTON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 SOUTH AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:VIVIAN
Mailing Address - State:LA
Mailing Address - Zip Code:71082-3220
Mailing Address - Country:US
Mailing Address - Phone:318-375-5500
Mailing Address - Fax:
Practice Address - Street 1:202 SOUTH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:VIVIAN
Practice Address - State:LA
Practice Address - Zip Code:71082-3220
Practice Address - Country:US
Practice Address - Phone:318-375-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-17
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07555225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist