Provider Demographics
NPI:1649596677
Name:DERR, JACQUE D JR (MPT, LOTR)
Entity Type:Individual
Prefix:
First Name:JACQUE
Middle Name:D
Last Name:DERR
Suffix:JR
Gender:M
Credentials:MPT, LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 856
Mailing Address - Street 2:
Mailing Address - City:OLLA
Mailing Address - State:LA
Mailing Address - Zip Code:71465-0856
Mailing Address - Country:US
Mailing Address - Phone:318-495-3312
Mailing Address - Fax:
Practice Address - Street 1:915 1ST ST
Practice Address - Street 2:
Practice Address - City:WINNFIELD
Practice Address - State:LA
Practice Address - Zip Code:71483-2945
Practice Address - Country:US
Practice Address - Phone:318-648-0212
Practice Address - Fax:318-648-3536
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06898225100000X
LAOTT.Z12112225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000OtherMEDICARE PENDING APPLICATION