Provider Demographics
NPI:1609009612
Name:PONCE, JERRY FREDERICK (RPT)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:FREDERICK
Last Name:PONCE
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2010 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 404
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-3507
Mailing Address - Country:US
Mailing Address - Phone:213-353-0003
Mailing Address - Fax:213-353-0004
Practice Address - Street 1:2010 WILSHIRE BLVD
Practice Address - Street 2:SUITE 404
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-3507
Practice Address - Country:US
Practice Address - Phone:213-353-0003
Practice Address - Fax:213-353-0004
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-25
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT35664225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist