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General NPI Number Information
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NPI Number | 1861007791
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Entity Type | Individual
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Provider Name | MAKESHA MONIQUE JEFFERSON PTA
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Gender | Female
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Dates
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Enumeration Date | 09/08/2020
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Last Update Date | 09/08/2020
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Provider Practice Location Address
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Address Line | 7500 DOLLARWAY RD STE 203
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City | WHITE HALL
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State | AR
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Zip | 71602-3085
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Country | US
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Telephone | 870-247-2099
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Fax | 870-619-1687
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Provider Business Mailing Address
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Address Line | 966 DUNNING AVE
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City | CAMDEN
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State | AR
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Zip | 71701-5401
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Country | US
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Telephone | 870-818-5576
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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 | 2331
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License Number State | AR
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