Provider Demographics
NPI:1245605005
Name:JAMISON PENNICOOKE, BEVERLY (PTA)
Entity Type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:
Last Name:JAMISON PENNICOOKE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3503 LINDEN AVE APT 201
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-4532
Mailing Address - Country:US
Mailing Address - Phone:562-400-8618
Mailing Address - Fax:
Practice Address - Street 1:330 GOLDEN SHORE DR
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802
Practice Address - Country:US
Practice Address - Phone:562-256-7550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT3766225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant