Provider Demographics
NPI:1295301687
Name:JONES, KEAGAN OMRI (PTA)
Entity type:Individual
Prefix:
First Name:KEAGAN
Middle Name:OMRI
Last Name:JONES
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:PO BOX 2109
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-2109
Mailing Address - Country:US
Mailing Address - Phone:479-967-2322
Mailing Address - Fax:479-967-2876
Practice Address - Street 1:1200 S ELMIRA AVE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72802-9646
Practice Address - Country:US
Practice Address - Phone:479-968-7118
Practice Address - Fax:479-968-8628
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA4633225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR267027721Medicaid