Provider Demographics
NPI:1548565476
Name:JETMORE-REICHARDT, MARY VICTORIA (MP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:VICTORIA
Last Name:JETMORE-REICHARDT
Suffix:
Gender:F
Credentials:MP
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 6493
Mailing Address - Street 2:22652 WATERS DRIVE
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-6493
Mailing Address - Country:US
Mailing Address - Phone:916-201-3908
Mailing Address - Fax:
Practice Address - Street 1:580 FOREST SHADE #4
Practice Address - Street 2:
Practice Address - City:CRESTLINE
Practice Address - State:CA
Practice Address - Zip Code:92325
Practice Address - Country:US
Practice Address - Phone:909-338-6477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10826225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist