Provider Demographics
NPI:1790484533
Name:MESHELL, JEREMY (PTA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:MESHELL
Suffix:
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 1:1301 ASHLEY ROAD 14 N
Mailing Address - Street 2:
Mailing Address - City:CROSSETT
Mailing Address - State:AR
Mailing Address - Zip Code:71635-8781
Mailing Address - Country:US
Mailing Address - Phone:870-951-1770
Mailing Address - Fax:
Practice Address - Street 1:1015 UNITY RD
Practice Address - Street 2:
Practice Address - City:CROSSETT
Practice Address - State:AR
Practice Address - Zip Code:71635-9443
Practice Address - Country:US
Practice Address - Phone:870-364-1243
Practice Address - Fax:870-364-1483
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4304225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant