Provider Demographics
NPI:1598390528
Name:CLEMENTE, JANICA PAULINE (PTA)
Entity Type:Individual
Prefix:
First Name:JANICA
Middle Name:PAULINE
Last Name:CLEMENTE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 BROCKTON AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3850
Mailing Address - Country:US
Mailing Address - Phone:714-425-7272
Mailing Address - Fax:
Practice Address - Street 1:12099 W WASHINGTON BLVD STE 408
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-2620
Practice Address - Country:US
Practice Address - Phone:424-228-4340
Practice Address - Fax:424-228-4109
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50501225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant