Provider Demographics
NPI:1083168926
Name:RAFFERTY, JEIEL
Entity Type:Individual
Prefix:
First Name:JEIEL
Middle Name:
Last Name:RAFFERTY
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 1:11140 RICHMONT RD
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2917
Mailing Address - Country:US
Mailing Address - Phone:541-521-0930
Mailing Address - Fax:
Practice Address - Street 1:11140 RICHMONT RD
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2917
Practice Address - Country:US
Practice Address - Phone:541-521-0930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48081225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA48081OtherCALIFORNIA PHYSICAL THERAPY BOARD