Provider Demographics
NPI:1427191980
Name:JEFFERSON, AMANDA MICHELE (PTA)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MICHELE
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3520 MAHLON MOORE RD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37174-2134
Mailing Address - Country:US
Mailing Address - Phone:931-489-5886
Mailing Address - Fax:
Practice Address - Street 1:5228 MAIN ST
Practice Address - Street 2:SUITE A2
Practice Address - City:SPRING HILL
Practice Address - State:TN
Practice Address - Zip Code:37174-7402
Practice Address - Country:US
Practice Address - Phone:931-486-0599
Practice Address - Fax:931-486-3962
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000002969225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN446631Medicare ID - Type Unspecified