Provider Demographics
NPI:1689671612
Name:HAYNES, LUKE JASON (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:LUKE
Middle Name:JASON
Last Name:HAYNES
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 237
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-0237
Mailing Address - Country:US
Mailing Address - Phone:817-594-9200
Mailing Address - Fax:817-594-9202
Practice Address - Street 1:1115 FORT WORTH HWY STE 1200
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086
Practice Address - Country:US
Practice Address - Phone:817-594-9200
Practice Address - Fax:817-594-9202
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1092740225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0877474-02Medicaid
TX0877474-02Medicaid