Provider Demographics
NPI:1629014063
Name:HOPPER, JERRY LYNN (RPT)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LYNN
Last Name:HOPPER
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:MR
Other - First Name:JERRY
Other - Middle Name:L
Other - Last Name:HOPPER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT BS
Mailing Address - Street 1:1815 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-3234
Mailing Address - Country:US
Mailing Address - Phone:760-256-2800
Mailing Address - Fax:760-256-2809
Practice Address - Street 1:1815 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-3234
Practice Address - Country:US
Practice Address - Phone:760-256-2800
Practice Address - Fax:760-256-2809
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13643225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT13643OtherPHYSICAL THERAPY LICENSE