Provider Demographics
NPI:1023745577
Name:JEFFERSON, AUSTIN TYLER (PT)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:TYLER
Last Name:JEFFERSON
Suffix:
Gender:M
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:PO BOX 9118
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55480-9118
Mailing Address - Country:US
Mailing Address - Phone:865-694-0062
Mailing Address - Fax:865-694-7907
Practice Address - Street 1:9430 PARK WEST BLVD STE 230
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4204
Practice Address - Country:US
Practice Address - Phone:865-560-8550
Practice Address - Fax:865-560-8551
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
TN14040225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty