Basic Information
| Provider Information | |||||||||
| NPI: | 1639186943 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEMONS | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2232 W HOUSTON ST | ||||||||
| Address2: | |||||||||
| City: | BROKEN ARROW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740123529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182599522 | ||||||||
| FaxNumber: | 9182599521 | ||||||||
| Practice Location | |||||||||
| Address1: | 2002 12TH AVE NW | ||||||||
| Address2: | STE A | ||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734011227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802269235 | ||||||||
| FaxNumber: | 5802269239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2801 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.