Provider Demographics
NPI:1447496450
Name:CARR, JEFFERY (ATC, LAT)
Entity type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:
Last Name:CARR
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3323 188TH ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-3503
Mailing Address - Country:US
Mailing Address - Phone:708-752-6027
Mailing Address - Fax:
Practice Address - Street 1:43 BANKVIEW DR
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1861
Practice Address - Country:US
Practice Address - Phone:815-469-6676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-22
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.002639172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker