Provider Demographics
NPI:1417296575
Name:CAMPBELL, JEREMY LEVI (DPT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:LEVI
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 HIGHWAY 457
Mailing Address - Street 2:
Mailing Address - City:LECOMPTE
Mailing Address - State:LA
Mailing Address - Zip Code:71346-8718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3446 MASONIC DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3615
Practice Address - Country:US
Practice Address - Phone:318-443-3311
Practice Address - Fax:318-443-0023
Is Sole Proprietor?:No
Enumeration Date:2013-02-11
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08505225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA08505OtherLOUISIANA PHYSICAL THERAPY BOARD
LA08505OtherLOUISIANA PHYSICAL THERAPY BOARD