Provider Demographics
NPI:1932495363
Name:GLEASON, JACQUELINE JUDITH (MSPT)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:JUDITH
Last Name:GLEASON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24792 CASTLE HL
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-7443
Mailing Address - Country:US
Mailing Address - Phone:949-363-5302
Mailing Address - Fax:
Practice Address - Street 1:24792 CASTLE HL
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-7443
Practice Address - Country:US
Practice Address - Phone:949-363-5302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29656225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist