Provider Demographics
NPI:1730532177
Name:JEANFAVRE, MICHAEL A
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:JEANFAVRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 NEWTON RD
Mailing Address - Street 2:STE 101
Mailing Address - City:PLAISTOW
Mailing Address - State:NH
Mailing Address - Zip Code:03865-2424
Mailing Address - Country:US
Mailing Address - Phone:978-388-7272
Mailing Address - Fax:978-388-7373
Practice Address - Street 1:607 BANTAM RD
Practice Address - Street 2:UNIT H
Practice Address - City:BANTAM
Practice Address - State:CT
Practice Address - Zip Code:06750-1634
Practice Address - Country:US
Practice Address - Phone:860-567-7787
Practice Address - Fax:860-567-7779
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10999225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist