Provider Demographics
NPI:1982845673
Name:JEFFERS, NICOLE (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:JEFFERS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3179 BRAVERTON ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:EDGEWATER
Mailing Address - State:MD
Mailing Address - Zip Code:21037-2665
Mailing Address - Country:US
Mailing Address - Phone:410-956-4308
Mailing Address - Fax:410-956-8038
Practice Address - Street 1:3179 BRAVERTON ST
Practice Address - Street 2:SUITE 201
Practice Address - City:EDGEWATER
Practice Address - State:MD
Practice Address - Zip Code:21037-2665
Practice Address - Country:US
Practice Address - Phone:410-956-4308
Practice Address - Fax:410-956-8038
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-10
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20944225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist