Provider Demographics
NPI:1194326587
Name:JEFFERSON, CANDICE ROCHELLE (PT,DPT)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:ROCHELLE
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:ROCHELLE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT,DPT
Mailing Address - Street 1:132 MEDICAL CIR STE 300
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:71852-8609
Mailing Address - Country:US
Mailing Address - Phone:870-845-8161
Mailing Address - Fax:
Practice Address - Street 1:132 MEDICAL CIR STE 300
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:AR
Practice Address - Zip Code:71852-8609
Practice Address - Country:US
Practice Address - Phone:870-845-8161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT4870225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist