Provider Demographics
NPI:1710561915
Name:CONLY, JAKE (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:
Last Name:CONLY
Suffix:
Gender:M
Credentials:PT, DPT
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 255
Mailing Address - Street 2:
Mailing Address - City:STONEWALL
Mailing Address - State:LA
Mailing Address - Zip Code:71078-0255
Mailing Address - Country:US
Mailing Address - Phone:318-470-3111
Mailing Address - Fax:318-935-9076
Practice Address - Street 1:5510 AIRLINE DR STE 104
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-6728
Practice Address - Country:US
Practice Address - Phone:318-935-9075
Practice Address - Fax:318-935-9076
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10888225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist