Provider Demographics
NPI:1558602292
Name:ANDERSEN, JESSICA (DPT)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:RITA
Other - Last Name:ROLDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30230 DISNEY LN
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-1232
Mailing Address - Country:US
Mailing Address - Phone:760-630-8658
Mailing Address - Fax:760-630-8658
Practice Address - Street 1:404 CAMINO DEL RIO S STE 508
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3503
Practice Address - Country:US
Practice Address - Phone:619-325-0154
Practice Address - Fax:619-325-0172
Is Sole Proprietor?:No
Enumeration Date:2013-03-05
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39611225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist