Provider Demographics
NPI:1972790822
Name:THORDERSON, JEDD ALAN (PT)
Entity Type:Individual
Prefix:MR
First Name:JEDD
Middle Name:ALAN
Last Name:THORDERSON
Suffix:
Gender:M
Credentials:PT
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Mailing Address - Street 1:PO BOX 44
Mailing Address - Street 2:206 B OXFORD ROAD
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-0044
Mailing Address - Country:US
Mailing Address - Phone:662-534-4445
Mailing Address - Fax:662-534-9449
Practice Address - Street 1:3437 TUPELO COMMONS
Practice Address - Street 2:SUITE 102
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-9791
Practice Address - Country:US
Practice Address - Phone:662-680-3200
Practice Address - Fax:662-680-5090
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2009-03-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MSPT4029225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS256599Medicare Oscar/Certification