Provider Demographics
NPI:1336367739
Name:ONEIL, JACK (RPT)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:ONEIL
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15739 PROFESSIONAL PLAZA
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-1452
Mailing Address - Country:US
Mailing Address - Phone:985-345-6000
Mailing Address - Fax:985-345-4498
Practice Address - Street 1:15739 PROFESSIONAL PLAZA
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1452
Practice Address - Country:US
Practice Address - Phone:985-345-6000
Practice Address - Fax:985-345-4498
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA00095225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1449819OtherUNITED HEALTH CARE
LA32005900OtherACS OWCP
LA11655OtherBCBS
LA06552OtherBCBS
LA720678856OtherOGB
LA5716136OtherFIRST HEALTH
LA684200OtherACN
LA684200OtherUNITED HEALTH CARE
LA56215Medicare ID - Type Unspecified