Provider Demographics
NPI:1780936732
Name:COULTER, JEFFREY ALAN (MS, ATC)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALAN
Last Name:COULTER
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WALDEN HEIGHTS DR
Mailing Address - Street 2:APT 513
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-7865
Mailing Address - Country:US
Mailing Address - Phone:803-673-9498
Mailing Address - Fax:
Practice Address - Street 1:2100 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-2126
Practice Address - Country:US
Practice Address - Phone:803-321-5184
Practice Address - Fax:800-882-9648
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer