Provider Demographics
NPI:1093590093
Name:GONGORA, JASMINE MIREYA (DPT)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:MIREYA
Last Name:GONGORA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JASMINE
Other - Middle Name:
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:408 HIGUERA ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6135
Mailing Address - Country:US
Mailing Address - Phone:805-788-0805
Mailing Address - Fax:805-788-0845
Practice Address - Street 1:81557 DR CARREON BLVD STE C4
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5562
Practice Address - Country:US
Practice Address - Phone:760-347-6195
Practice Address - Fax:760-347-2849
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT305678225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist