Provider Demographics
NPI:1215902465
Name:JEFFORDS, AMY BETH (MPT)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:BETH
Last Name:JEFFORDS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2787 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-2541
Mailing Address - Country:US
Mailing Address - Phone:618-524-7336
Mailing Address - Fax:618-524-7578
Practice Address - Street 1:727 E 12TH ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-2608
Practice Address - Country:US
Practice Address - Phone:618-524-7336
Practice Address - Fax:618-524-7578
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004384225100000X
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK01793Medicare ID - Type UnspecifiedPROVIDER NUMBER
KY5018309Medicare ID - Type UnspecifiedPROVIDER NUMBER