Provider Demographics
NPI:1790092989
Name:BUSH, JAMES KENNETH JR (PTA)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:KENNETH
Last Name:BUSH
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17764 SUNDIAL CT
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46062-7640
Mailing Address - Country:US
Mailing Address - Phone:317-979-4006
Mailing Address - Fax:
Practice Address - Street 1:17764 SUNDIAL CT
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46062-7640
Practice Address - Country:US
Practice Address - Phone:317-979-4006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004039A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant