Provider Demographics
NPI:1376628552
Name:MONALOY, JESSICA (PT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MONALOY
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:PO BOX 550275
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96155-0275
Mailing Address - Country:US
Mailing Address - Phone:530-721-3253
Mailing Address - Fax:530-285-2002
Practice Address - Street 1:3200 US HIGHWAY 50
Practice Address - Street 2:UNIT 5
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-9207
Practice Address - Country:US
Practice Address - Phone:530-721-3253
Practice Address - Fax:530-285-2002
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25234225100000X
CA25234225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT252340OtherMEDICARE PPIN
CAZZZ32617ZMedicare ID - Type UnspecifiedGROUP ID
CAQ64802Medicare UPIN