Provider Demographics
NPI:1376909846
Name:DELA REA, JEANIE
Entity Type:Individual
Prefix:
First Name:JEANIE
Middle Name:
Last Name:DELA REA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10106 GOTHIC AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-1214
Mailing Address - Country:US
Mailing Address - Phone:818-388-7256
Mailing Address - Fax:
Practice Address - Street 1:16260 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2203
Practice Address - Country:US
Practice Address - Phone:818-986-1977
Practice Address - Fax:818-986-4757
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT5105225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant