Provider Demographics
NPI:1861444200
Name:RILEY, JASON (MPT, ATC, LAT, CKTP)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:RILEY
Suffix:
Gender:M
Credentials:MPT, ATC, LAT, CKTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 WINKLER WAY
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-6527
Mailing Address - Country:US
Mailing Address - Phone:318-537-4376
Mailing Address - Fax:318-302-6001
Practice Address - Street 1:650 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104
Practice Address - Country:US
Practice Address - Phone:318-302-6000
Practice Address - Fax:318-302-6001
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0556R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4C265CR61Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER