Provider Demographics
NPI:1952052490
Name:JEFFERSON, MATTHEW B (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:B
Last Name:JEFFERSON
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8347A GREENSBORO DR
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-3530
Mailing Address - Country:US
Mailing Address - Phone:571-888-5193
Mailing Address - Fax:
Practice Address - Street 1:8347A GREENSBORO DR
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-3530
Practice Address - Country:US
Practice Address - Phone:571-888-5193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-17
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019012155225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist