Provider Demographics
NPI:1154377851
Name:FAULK, JARRAD W (PT)
Entity type:Individual
Prefix:
First Name:JARRAD
Middle Name:W
Last Name:FAULK
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 1:2804 CUBA BLVD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-2014
Mailing Address - Country:US
Mailing Address - Phone:318-343-3149
Mailing Address - Fax:318-325-2022
Practice Address - Street 1:3001 ARMAND ST STE F
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3761
Practice Address - Country:US
Practice Address - Phone:318-340-6300
Practice Address - Fax:318-340-6323
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06930174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist