Provider Demographics
NPI:1093896813
Name:CARLSON, JEFFREY CHARLES (PT)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:CHARLES
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208B VFW PKWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-4349
Mailing Address - Country:US
Mailing Address - Phone:617-325-7246
Mailing Address - Fax:
Practice Address - Street 1:1208B VFW PKWY
Practice Address - Street 2:SUITE 202
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-4349
Practice Address - Country:US
Practice Address - Phone:617-325-7246
Practice Address - Fax:617-325-7282
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16796225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY69517Medicare ID - Type Unspecified