Provider Demographics
NPI:1912301128
Name:JACKSON PARISH THERAPY CENTER LLC
Entity Type:Organization
Organization Name:JACKSON PARISH THERAPY CENTER LLC
Other - Org Name:PT PLUS THERAPY AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:VON
Authorized Official - Last Name:YARBOROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:318-259-9899
Mailing Address - Street 1:730 CELEBRITY DR
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-3875
Mailing Address - Country:US
Mailing Address - Phone:318-224-8994
Mailing Address - Fax:317-259-9897
Practice Address - Street 1:730 CELEBRITY DR
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3875
Practice Address - Country:US
Practice Address - Phone:318-224-8994
Practice Address - Fax:317-259-9897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5CB70Medicare UPIN