Provider Demographics
NPI:1972741197
Name:JELLUM, BRITTANY M (PTA)
Entity type:Individual
Prefix:MS
First Name:BRITTANY
Middle Name:M
Last Name:JELLUM
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 1:1800 BUCKNER ST
Mailing Address - Street 2:SUITE C 200
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4440
Mailing Address - Country:US
Mailing Address - Phone:318-227-9002
Mailing Address - Fax:318-227-9025
Practice Address - Street 1:1800 BUCKNER ST
Practice Address - Street 2:SUITE C 200
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4440
Practice Address - Country:US
Practice Address - Phone:318-227-9002
Practice Address - Fax:318-227-9025
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA7232225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant