Provider Demographics
NPI:1629358502
Name:THIBODEAU, JEFFREY M (DPT)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:M
Last Name:THIBODEAU
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 ROBIE ST
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-1726
Mailing Address - Country:US
Mailing Address - Phone:207-432-7536
Mailing Address - Fax:
Practice Address - Street 1:180 WATERMAN DR
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3659
Practice Address - Country:US
Practice Address - Phone:207-550-0660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT3739225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist