Provider Demographics
NPI:1922658301
Name:JEFFERSON, JAMES KENNETH (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:KENNETH
Last Name:JEFFERSON
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 S HESTER ST APT 319
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-3415
Mailing Address - Country:US
Mailing Address - Phone:910-538-7980
Mailing Address - Fax:
Practice Address - Street 1:200 ATHLETIC CENTER GALLAGHER IBA ARENA
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74078-0001
Practice Address - Country:US
Practice Address - Phone:910-538-7980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer