Provider Demographics
NPI:1639253933
Name:CHAMBERLAIN, JERRY M (PT)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:M
Last Name:CHAMBERLAIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:420 W PINHOOK RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2131
Mailing Address - Country:US
Mailing Address - Phone:337-233-1307
Mailing Address - Fax:337-233-5764
Practice Address - Street 1:4027 I-49 SOUTH SERVICE RD
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-0757
Practice Address - Country:US
Practice Address - Phone:337-948-4214
Practice Address - Fax:337-942-9979
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA00279225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5657315OtherAETNA
LA5657315OtherAETNA