Provider Demographics
NPI:1346897139
Name:SHORT, JEFFERY LUCAS (DPT)
Entity Type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:LUCAS
Last Name:SHORT
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 1:5391 GAMALIEL RD
Mailing Address - Street 2:
Mailing Address - City:TOMPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42167-6740
Mailing Address - Country:US
Mailing Address - Phone:270-407-8454
Mailing Address - Fax:
Practice Address - Street 1:20996 REDWOOD RD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5918
Practice Address - Country:US
Practice Address - Phone:510-537-0272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007754225100000X
CA297756225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist