Provider Demographics
NPI:1003108366
Name:COAKLEY, JEREMY R (PTA)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:R
Last Name:COAKLEY
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 1:515 GREENE DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42345-1409
Mailing Address - Country:US
Mailing Address - Phone:270-338-5400
Mailing Address - Fax:
Practice Address - Street 1:515 GREENE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42345-1409
Practice Address - Country:US
Practice Address - Phone:270-338-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-05
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA02641225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant