Provider Demographics
NPI:1164558458
Name:DENISTON, JEFF (PT)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:DENISTON
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 1:709 W MATTHEWS AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3456
Mailing Address - Country:US
Mailing Address - Phone:870-275-1975
Mailing Address - Fax:
Practice Address - Street 1:505 E MATTHEWS AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3144
Practice Address - Country:US
Practice Address - Phone:870-932-9567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 2232174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist