Provider Demographics
NPI:1821261538
Name:JEFFERSON, TONGALA RENEE
Entity Type:Individual
Prefix:
First Name:TONGALA
Middle Name:RENEE
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1257 N PINES DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-2723
Mailing Address - Country:US
Mailing Address - Phone:318-678-0656
Mailing Address - Fax:
Practice Address - Street 1:1257 N PINES DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-2723
Practice Address - Country:US
Practice Address - Phone:318-678-0656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2065062225200000X
LAA4521225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant