Provider Demographics
NPI:1356042634
Name:TAVERA, JEWELS ALYSSA (DPT)
Entity type:Individual
Prefix:
First Name:JEWELS
Middle Name:ALYSSA
Last Name:TAVERA
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 1:1610 N AVENUE 55
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-1107
Mailing Address - Country:US
Mailing Address - Phone:213-453-3273
Mailing Address - Fax:
Practice Address - Street 1:8550 LEE HWY STE 450
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-1519
Practice Address - Country:US
Practice Address - Phone:703-208-1002
Practice Address - Fax:703-208-1127
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-14
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
CA303708225100000X
VA2305215610225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist