Provider Demographics
NPI:1801036819
Name:SUPER, JESSICA L (PT, DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:SUPER
Suffix:
Gender:F
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44651 VILLAGE CT STE 120
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-3823
Mailing Address - Country:US
Mailing Address - Phone:760-501-6655
Mailing Address - Fax:760-262-3773
Practice Address - Street 1:44651 VILLAGE CT STE 120
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-3823
Practice Address - Country:US
Practice Address - Phone:760-501-6655
Practice Address - Fax:760-262-3773
Is Sole Proprietor?:No
Enumeration Date:2009-03-03
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT35434225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist