Provider Demographics
NPI:1164998316
Name:MICHAELSON, JEFFRY E (PT)
Entity Type:Individual
Prefix:
First Name:JEFFRY
Middle Name:E
Last Name:MICHAELSON
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 1:288 N PINNACLE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05676-1120
Mailing Address - Country:US
Mailing Address - Phone:802-882-8480
Mailing Address - Fax:
Practice Address - Street 1:577 WASHINGTON HWY
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:VT
Practice Address - Zip Code:05661-8972
Practice Address - Country:US
Practice Address - Phone:802-888-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0090189225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist