Provider Demographics
NPI:1740622109
Name:HOLM, JEFFERSON WAYNE (DPT, PT, CBIS)
Entity type:Individual
Prefix:DR
First Name:JEFFERSON
Middle Name:WAYNE
Last Name:HOLM
Suffix:
Gender:M
Credentials:DPT, PT, CBIS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3160 N ARIZONA AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-7122
Mailing Address - Country:US
Mailing Address - Phone:480-244-7011
Mailing Address - Fax:480-699-5085
Practice Address - Street 1:3961 E GUADALUPE RD STE 1
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-3266
Practice Address - Country:US
Practice Address - Phone:480-699-4845
Practice Address - Fax:480-699-5085
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-25
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390162251N0400X
AZ93432251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology