Provider Demographics
NPI:1760992531
Name:VAN SOEST, JESSICA LORRAINE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LORRAINE
Last Name:VAN SOEST
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 1:460 BOULEVARD WAY
Mailing Address - Street 2:STE 2D
Mailing Address - City:PIEDMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94610-1563
Mailing Address - Country:US
Mailing Address - Phone:510-922-8872
Mailing Address - Fax:510-291-2820
Practice Address - Street 1:2450 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-5996
Practice Address - Country:US
Practice Address - Phone:510-577-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-06
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293825225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist