Provider Demographics
NPI:1205855921
Name:VALDES, JENNIFER MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:VALDES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 811386
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90081
Mailing Address - Country:US
Mailing Address - Phone:909-997-3134
Mailing Address - Fax:909-494-4326
Practice Address - Street 1:1400 QUAIL ST
Practice Address - Street 2:UNIT 110
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92662
Practice Address - Country:US
Practice Address - Phone:909-997-3134
Practice Address - Fax:909-494-4326
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27874225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist