Provider Demographics
NPI:1912039058
Name:LEITHERER, JERALD W (PT)
Entity Type:Individual
Prefix:
First Name:JERALD
Middle Name:W
Last Name:LEITHERER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 BUENA VISTA ST
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-7210
Mailing Address - Country:US
Mailing Address - Phone:530-273-4152
Mailing Address - Fax:
Practice Address - Street 1:10565 BRUNSWICK RD
Practice Address - Street 2:SUITE 4
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-9053
Practice Address - Country:US
Practice Address - Phone:530-273-4152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT32624225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist