Provider Demographics
NPI:1821426859
Name:WATERS, JEFFRIE GLENN (PTA)
Entity Type:Individual
Prefix:MR
First Name:JEFFRIE
Middle Name:GLENN
Last Name:WATERS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 PEDRAS RD APT E203
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-2347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1685 SHAFFER RD
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301-4456
Practice Address - Country:US
Practice Address - Phone:209-357-3420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-30
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9195225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9195OtherPHYSICAL THERAPIST ASSISTANT LICENSE NUMBER