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General NPI Number Information
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NPI Number | 1275110603
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Entity Type | Individual
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Provider Name | COLE JEAVONS PTA
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Gender | Male
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Dates
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Enumeration Date | 03/24/2021
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Last Update Date | 03/24/2021
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Provider Practice Location Address
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Address Line | 1414 HOSPITAL ST
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City | GREENVILLE
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State | MS
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Zip | 38703-3217
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Country | US
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Telephone | 601-946-0312
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Fax |
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Provider Business Mailing Address
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Address Line | 360 W 13TH AVE UNIT 820
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City | DENVER
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State | CO
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Zip | 80204-2728
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Country | US
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Telephone | 601-946-0312
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA6927
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License Number State | MS
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