Provider Demographics
NPI:1679010805
Name:JAKKULA, SHEEBA SUNITHA
Entity Type:Individual
Prefix:
First Name:SHEEBA
Middle Name:SUNITHA
Last Name:JAKKULA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3147 HUMBERSIDE CT
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-3677
Mailing Address - Country:US
Mailing Address - Phone:408-603-0696
Mailing Address - Fax:
Practice Address - Street 1:841 BLOSSOM HILL RD STE 103
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-2704
Practice Address - Country:US
Practice Address - Phone:408-365-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT292475225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist