Provider Demographics
NPI:1194712687
Name:WIED, JESSE LEE (PT)
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:LEE
Last Name:WIED
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 1:1815 ROSELAWN AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5433
Mailing Address - Country:US
Mailing Address - Phone:318-322-7050
Mailing Address - Fax:318-322-7031
Practice Address - Street 1:1815 ROSELAWN AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5433
Practice Address - Country:US
Practice Address - Phone:318-322-7050
Practice Address - Fax:318-322-7031
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA02241R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1551813Medicaid
LA5X389Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER