Provider Demographics
NPI:1720060189
Name:JEFFERS, ANGELA RITA (PTA)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:RITA
Last Name:JEFFERS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:ANGELA
Other - Middle Name:RITA
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:1111 DELAFIELD ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3417
Mailing Address - Country:US
Mailing Address - Phone:262-544-5311
Mailing Address - Fax:262-544-6820
Practice Address - Street 1:1111 DELAFIELD ST
Practice Address - Street 2:SUITE 120
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3417
Practice Address - Country:US
Practice Address - Phone:262-544-5311
Practice Address - Fax:262-544-6820
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI613225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant