Provider Demographics
NPI:1275110603
Name:JEAVONS, COLE (PTA)
Entity Type:Individual
Prefix:
First Name:COLE
Middle Name:
Last Name:JEAVONS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 W 13TH AVE UNIT 820
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-2728
Mailing Address - Country:US
Mailing Address - Phone:601-946-0312
Mailing Address - Fax:
Practice Address - Street 1:1414 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-3217
Practice Address - Country:US
Practice Address - Phone:601-946-0312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA6927225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSPTA6927OtherPTA LICENSE