Provider Demographics
NPI:1922747864
Name:HENNESSY, JEFFREY (DPT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:HENNESSY
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 1:2001 WILSHIRE BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5683
Mailing Address - Country:US
Mailing Address - Phone:310-829-3320
Mailing Address - Fax:
Practice Address - Street 1:2001 WILSHIRE BLVD STE 310
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5683
Practice Address - Country:US
Practice Address - Phone:310-829-3320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0014540225100000X
CA304200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist