MEDICARE: DARLA L JEFFERSON LPTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	829	NC

General Provider Information

NPI Number	:	1417071549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARLA L JEFFERSON LPTA

Provider Business Mailing Address
First Line	:	333 HOWARD ST
Second Line	:
City	:	MOUNT AIRY
State	:	NC
Zip	:	27030-2933
Country	:	US
Telephone Number	:	336-789-9173
Fax Number	:

Provider Business Practice Location Address
First Line	:	2206 RIDGE CREST LN
Second Line	:
City	:	MOUNT AIRY
State	:	NC
Zip	:	27030-2483
Country	:	US
Telephone Number	:	336-786-9132
Fax Number	:	336-786-9153

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	07/08/2007

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