Provider Demographics
NPI:1609866300
Name:PAXSON, JEFFREY LEE (ATC,L CSCS)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:LEE
Last Name:PAXSON
Suffix:
Gender:M
Credentials:ATC,L CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11001 TIMOTHY LN
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:IN
Mailing Address - Zip Code:46783-9618
Mailing Address - Country:US
Mailing Address - Phone:260-638-4767
Mailing Address - Fax:
Practice Address - Street 1:630 E JENSEN ST
Practice Address - Street 2:193
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-2590
Practice Address - Country:US
Practice Address - Phone:480-699-3091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ01892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer