Provider Demographics
NPI:1487723946
Name:MADDOX, JEFF (PT)
Entity type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:MADDOX
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 822394
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39182-2394
Mailing Address - Country:US
Mailing Address - Phone:601-638-4076
Mailing Address - Fax:601-638-4979
Practice Address - Street 1:1901 MISSION 66
Practice Address - Street 2:SUITE A
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3711
Practice Address - Country:US
Practice Address - Phone:601-638-4076
Practice Address - Fax:601-638-4979
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT 1303225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03701390Medicaid
MS25-4533Medicare ID - Type Unspecified