Provider Demographics
NPI:1598534059
Name:NISSEN, JYLLIAN (PTA)
Entity Type:Individual
Prefix:
First Name:JYLLIAN
Middle Name:
Last Name:NISSEN
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 1:764 SOLANO
Mailing Address - Street 2:
Mailing Address - City:SOLEDAD
Mailing Address - State:CA
Mailing Address - Zip Code:93960-3380
Mailing Address - Country:US
Mailing Address - Phone:909-229-6589
Mailing Address - Fax:
Practice Address - Street 1:408 MAIN ST
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-3306
Practice Address - Country:US
Practice Address - Phone:831-273-0124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52902225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant