Provider Demographics
NPI:1871339952
Name:MACKIN, JEFFERY (PTA)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
Last Name:MACKIN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3404 DAVIE RD APT 301
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-1628
Mailing Address - Country:US
Mailing Address - Phone:954-496-0542
Mailing Address - Fax:
Practice Address - Street 1:3404 DAVIE RD APT 301
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-1628
Practice Address - Country:US
Practice Address - Phone:954-496-0542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28770225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant