Provider Demographics
NPI:1689729758
Name:GOLD, JESSICA L (DC, PTA)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:L
Last Name:GOLD
Suffix:
Gender:F
Credentials:DC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 GREENBRIAR CIR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-3543
Mailing Address - Country:US
Mailing Address - Phone:760-213-0506
Mailing Address - Fax:
Practice Address - Street 1:733 GREENBRIAR CIRCLE
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954
Practice Address - Country:US
Practice Address - Phone:760-213-0506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28890111N00000X
CAAT5090225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV01398Medicare UPIN