Provider Demographics
NPI:1205130259
Name:FERNANDEZ, JENNIFER LYNN (DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 BUSINESS CENTER DR STE 127
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3434
Mailing Address - Country:US
Mailing Address - Phone:909-890-9030
Mailing Address - Fax:909-890-4393
Practice Address - Street 1:1845 BUSINESS CENTER DR STE 127
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408
Practice Address - Country:US
Practice Address - Phone:909-890-9030
Practice Address - Fax:909-890-4393
Is Sole Proprietor?:No
Enumeration Date:2011-01-05
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT37456225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0273923OtherSTATE OF WASHINGTON DEPT. OF LABOR AND INDUSTRIES
CA0PT374560OtherBLUE SHIELD OF CALIFORNIA
CA0PT374560OtherBLUE SHIELD OF CALIFORNIA