Provider Demographics
NPI:1902387228
Name:LAMOG, JESSE TABISULA (DPT)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:TABISULA
Last Name:LAMOG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3191 MISSION INN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-4188
Mailing Address - Country:US
Mailing Address - Phone:951-376-2692
Mailing Address - Fax:951-684-2980
Practice Address - Street 1:14682 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-9505
Practice Address - Country:US
Practice Address - Phone:951-376-2692
Practice Address - Fax:951-684-2980
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT295254225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist