Provider Demographics
NPI:1558443226
Name:HARRIS, JIMMY WAYNE JR (P T)
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:WAYNE
Last Name:HARRIS
Suffix:JR
Gender:M
Credentials:P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 BENTON RD
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3404
Mailing Address - Country:US
Mailing Address - Phone:318-747-2200
Mailing Address - Fax:318-747-2255
Practice Address - Street 1:2204 BENTON RD
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3404
Practice Address - Country:US
Practice Address - Phone:318-747-2200
Practice Address - Fax:318-747-2255
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA032042251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4B5275CB60Medicare ID - Type UnspecifiedPHYSICAL THERAPIST