Provider Demographics
NPI:1215409974
Name:MARTIN, JEANDRA S (PT)
Entity Type:Individual
Prefix:
First Name:JEANDRA
Middle Name:S
Last Name:MARTIN
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 1:1850 N RIVERSIDE AVE STE 240
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-8082
Mailing Address - Country:US
Mailing Address - Phone:909-258-2220
Mailing Address - Fax:909-258-2102
Practice Address - Street 1:1850 N RIVERSIDE AVE STE 240
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-8082
Practice Address - Country:US
Practice Address - Phone:909-258-2220
Practice Address - Fax:909-258-2102
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT295851225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA295851OtherPT LICENSE