Provider Demographics
NPI:1083376602
Name:KING, JEFFREY TRAVIS (DPT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:TRAVIS
Last Name:KING
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24014 W RENWICK RD UNIT 206
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-8711
Mailing Address - Country:US
Mailing Address - Phone:800-974-4378
Mailing Address - Fax:630-515-1536
Practice Address - Street 1:4660 S HAGADORN RD STE 160
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6804
Practice Address - Country:US
Practice Address - Phone:800-974-4378
Practice Address - Fax:630-515-1536
Is Sole Proprietor?:No
Enumeration Date:2021-10-11
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15634225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist