Provider Demographics
NPI:1619457744
Name:WEAKLEY, J. BENJAMIN
Entity Type:Individual
Prefix:
First Name:J.
Middle Name:BENJAMIN
Last Name:WEAKLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2713 SE I ST STE 5
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-0078
Mailing Address - Country:US
Mailing Address - Phone:479-250-4355
Mailing Address - Fax:
Practice Address - Street 1:2713 SE I ST STE 5
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-0078
Practice Address - Country:US
Practice Address - Phone:479-250-4355
Practice Address - Fax:479-553-7954
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty