Provider Demographics
NPI:1477966919
Name:TICE, JESSICA (DPT)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:TICE
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 1:9089 CLAIREMONT MESA BLVD
Mailing Address - Street 2:200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3300 WEBSTER ST
Practice Address - Street 2:703
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3117
Practice Address - Country:US
Practice Address - Phone:510-835-5633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38541225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist