Provider Demographics
NPI:1831136498
Name:WILLS, JEFFREY W (PT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:W
Last Name:WILLS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 MONARCH ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1497
Mailing Address - Country:US
Mailing Address - Phone:859-219-0211
Mailing Address - Fax:859-219-0241
Practice Address - Street 1:1010 MONARCH ST
Practice Address - Street 2:SUITE 150
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1497
Practice Address - Country:US
Practice Address - Phone:859-219-0211
Practice Address - Fax:859-219-0241
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3720225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000385840OtherBC/BS
KYP400037267OtherMEDICARE PTAN
KY961102Medicare ID - Type UnspecifiedMEDICARE #