Provider Demographics
NPI:1952462699
Name:FERGUSON, JIM PARKER (DPT ECS)
Entity Type:Individual
Prefix:DR
First Name:JIM
Middle Name:PARKER
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:DPT ECS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 E HIGHLAND AVENUE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404
Mailing Address - Country:US
Mailing Address - Phone:909-884-5368
Mailing Address - Fax:909-884-4138
Practice Address - Street 1:1255 E HIGHLAND AVENUE
Practice Address - Street 2:SUITE 108
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404
Practice Address - Country:US
Practice Address - Phone:909-884-5368
Practice Address - Fax:909-884-4138
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAEN 36174400000X
CA16695225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered174400000XOther Service ProvidersSpecialist
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OPT166950Medicare ID - Type Unspecified