Provider Demographics
NPI:1821429358
Name:FREDERICO, JON (DPT)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:FREDERICO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24630 WASHINGTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6131
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:6860 BROCKTON AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3821
Practice Address - Country:US
Practice Address - Phone:951-534-0600
Practice Address - Fax:951-534-0605
Is Sole Proprietor?:No
Enumeration Date:2013-12-10
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT40724225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA112200OtherMEDICARE PTAN