Provider Demographics
NPI:1568971422
Name:JEFFERS, GREGORY STEPHEN (MS, LAT, PES, CES)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:STEPHEN
Last Name:JEFFERS
Suffix:
Gender:M
Credentials:MS, LAT, PES, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5424 FM 1252 W
Mailing Address - Street 2:
Mailing Address - City:GLADEWATER
Mailing Address - State:TX
Mailing Address - Zip Code:75647-6519
Mailing Address - Country:US
Mailing Address - Phone:903-283-8174
Mailing Address - Fax:903-986-1103
Practice Address - Street 1:5424 FM 1252 W
Practice Address - Street 2:
Practice Address - City:GLADEWATER
Practice Address - State:TX
Practice Address - Zip Code:75647-6519
Practice Address - Country:US
Practice Address - Phone:903-283-8174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-23
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT49202255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAT4920OtherTEXAS ATHLETIC TRAINER LICENSURE