Provider Demographics
NPI:1174650659
Name:STILLWELL, JEREMY (PT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:STILLWELL
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 1:2100 OAK PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7864
Mailing Address - Country:US
Mailing Address - Phone:337-310-5116
Mailing Address - Fax:337-310-5118
Practice Address - Street 1:217 SAM HOUSTON JONES PKWY
Practice Address - Street 2:STE 103
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70611-5644
Practice Address - Country:US
Practice Address - Phone:337-217-0997
Practice Address - Fax:337-217-0998
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA02441225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1548928Medicaid
LA196543Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER