Provider Demographics
NPI:1851745822
Name:NITOLLAMA, JENNIFER (PT, PCS)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:NITOLLAMA
Suffix:
Gender:F
Credentials:PT, PCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11402 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-2620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11402 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-2620
Practice Address - Country:US
Practice Address - Phone:714-651-6008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-15
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36549225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics