Provider Demographics
NPI:1891254710
Name:CORDERO, JESSICA DAMARIS
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:DAMARIS
Last Name:CORDERO
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:DAMARIS
Other - Last Name:CORDERO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:1957 RAINIER DR
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-5132
Mailing Address - Country:US
Mailing Address - Phone:916-206-9500
Mailing Address - Fax:
Practice Address - Street 1:312 W J ST
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-4073
Practice Address - Country:US
Practice Address - Phone:209-827-6178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT296453208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation