Provider Demographics
NPI:1083311344
Name:CRISOSTO, JAYLEN WILSON (DPT)
Entity Type:Individual
Prefix:
First Name:JAYLEN
Middle Name:WILSON
Last Name:CRISOSTO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24500 WATTENBURG RD
Mailing Address - Street 2:
Mailing Address - City:COVELO
Mailing Address - State:CA
Mailing Address - Zip Code:95428-9758
Mailing Address - Country:US
Mailing Address - Phone:707-489-2182
Mailing Address - Fax:
Practice Address - Street 1:2909 N 118TH ST STE 200
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-3643
Practice Address - Country:US
Practice Address - Phone:402-509-5532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR63660225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist