Provider Demographics
NPI:1972095586
Name:CORNETT, JAYLA BETHANY (PTA)
Entity type:Individual
Prefix:MS
First Name:JAYLA
Middle Name:BETHANY
Last Name:CORNETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17709 OLD JEFFERSON HWY STE A
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-3977
Mailing Address - Country:US
Mailing Address - Phone:225-677-8400
Mailing Address - Fax:225-977-8484
Practice Address - Street 1:17709 OLD JEFFERSON HWY STE A
Practice Address - Street 2:
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-3977
Practice Address - Country:US
Practice Address - Phone:225-677-8400
Practice Address - Fax:225-977-8484
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA09949225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1356400345OtherNPI