Provider Demographics
NPI:1861007791
Name:JEFFERSON, MAKESHA MONIQUE (PTA)
Entity Type:Individual
Prefix:
First Name:MAKESHA
Middle Name:MONIQUE
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:966 DUNNING AVE
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:AR
Mailing Address - Zip Code:71701-5401
Mailing Address - Country:US
Mailing Address - Phone:870-818-5576
Mailing Address - Fax:
Practice Address - Street 1:7500 DOLLARWAY RD STE 203
Practice Address - Street 2:
Practice Address - City:WHITE HALL
Practice Address - State:AR
Practice Address - Zip Code:71602-3085
Practice Address - Country:US
Practice Address - Phone:870-247-2099
Practice Address - Fax:870-619-1687
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2331225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant