Healthcare Provider Details

I. General information

NPI: 1356893051
Provider Name (Legal Business Name): JEFFERSON W MEADORS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2016
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 SAGAMORE PKWY W STE 917
WEST LAFAYETTE IN
47906-1443
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 765-463-0710
  • Fax: 765-463-0711
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberCP032352A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA.011065
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: