Provider Demographics
NPI:1578867487
Name:LANDRY, JACKI (PTA)
Entity Type:Individual
Prefix:
First Name:JACKI
Middle Name:
Last Name:LANDRY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 SECTION LINE RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-6482
Mailing Address - Country:US
Mailing Address - Phone:501-520-0504
Mailing Address - Fax:501-520-0245
Practice Address - Street 1:321 SECTION LINE RD
Practice Address - Street 2:SUITE E
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6482
Practice Address - Country:US
Practice Address - Phone:501-520-0504
Practice Address - Fax:501-520-0245
Is Sole Proprietor?:No
Enumeration Date:2011-01-06
Last Update Date:2014-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1293225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1293OtherPTA LICENSE