Provider Demographics
NPI:1104069913
Name:LUM, JEFFREY (PT, MPT, DIP MDT)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:LUM
Suffix:
Gender:M
Credentials:PT, MPT, DIP MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 QUAIL VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-8051
Mailing Address - Country:US
Mailing Address - Phone:512-559-6551
Mailing Address - Fax:
Practice Address - Street 1:601 QUAIL VALLEY DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-8051
Practice Address - Country:US
Practice Address - Phone:512-559-6551
Practice Address - Fax:512-591-0789
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT35353225100000X
TX1249361225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACG020ZMedicare PIN