Provider Demographics
NPI:1255654547
Name:AVERY, JESSICA (DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:AVERY
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 1:1695 VIA AMIGOS
Mailing Address - Street 2:
Mailing Address - City:SAN LORENZO
Mailing Address - State:CA
Mailing Address - Zip Code:94580-2009
Mailing Address - Country:US
Mailing Address - Phone:510-909-9266
Mailing Address - Fax:
Practice Address - Street 1:1695 VIA AMIGOS
Practice Address - Street 2:
Practice Address - City:SAN LORENZO
Practice Address - State:CA
Practice Address - Zip Code:94580-2009
Practice Address - Country:US
Practice Address - Phone:510-909-9266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-01
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT323532251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics