Provider Demographics
NPI:1457500712
Name:WILSON, JODI LEE (DPT)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:LEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16551 GABARDA RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2813
Mailing Address - Country:US
Mailing Address - Phone:415-425-5463
Mailing Address - Fax:
Practice Address - Street 1:3450 BONITA RD
Practice Address - Street 2:SUITE 105
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-3248
Practice Address - Country:US
Practice Address - Phone:619-425-1084
Practice Address - Fax:619-425-1858
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34843225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist