Provider Demographics
NPI:1073636478
Name:MITSUMORI, JANE M (PT)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:M
Last Name:MITSUMORI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9122 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-3405
Mailing Address - Country:US
Mailing Address - Phone:714-962-1780
Mailing Address - Fax:714-378-5166
Practice Address - Street 1:9122 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-3405
Practice Address - Country:US
Practice Address - Phone:714-962-1780
Practice Address - Fax:714-378-5166
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT100432251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT10043OtherSTATE LICENSE #