Provider Demographics
NPI:1699061770
Name:KEIGLEY, JASON TODD (PT)
Entity type:Individual
Prefix:PROF
First Name:JASON
Middle Name:TODD
Last Name:KEIGLEY
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 1:1709 W PRIEN LAKE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8360
Mailing Address - Country:US
Mailing Address - Phone:337-474-5201
Mailing Address - Fax:337-474-5524
Practice Address - Street 1:1709 W PRIEN LAKE RD
Practice Address - Street 2:SUITE B
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8360
Practice Address - Country:US
Practice Address - Phone:337-474-5201
Practice Address - Fax:337-474-5524
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08101225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist