Provider Demographics
NPI:1619341856
Name:CLEVENGER, JEFFREY (MS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:CLEVENGER
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2043 E 430 S
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909-8105
Mailing Address - Country:US
Mailing Address - Phone:765-772-4711
Mailing Address - Fax:
Practice Address - Street 1:1801 S 18TH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-2011
Practice Address - Country:US
Practice Address - Phone:765-772-4711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-28
Last Update Date:2015-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000065A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer