Provider Demographics
NPI:1932963717
Name:LAVERY, JEFFREY BRAYDON (PT, DPT, CPT, CES)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:BRAYDON
Last Name:LAVERY
Suffix:
Gender:M
Credentials:PT, DPT, CPT, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3983 W DEER HORN DR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-6012
Mailing Address - Country:US
Mailing Address - Phone:801-347-8949
Mailing Address - Fax:
Practice Address - Street 1:13034 S GLACIER POINT CIR
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8882
Practice Address - Country:US
Practice Address - Phone:801-347-8949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13243963-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist