Provider Demographics
NPI:1700043221
Name:MODICA, JESSE RUSSELL (PT, DPT, MS)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:RUSSELL
Last Name:MODICA
Suffix:
Gender:M
Credentials:PT, DPT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 N REDWOOD DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1969
Mailing Address - Country:US
Mailing Address - Phone:414-499-0278
Mailing Address - Fax:
Practice Address - Street 1:165 N REDWOOD DR
Practice Address - Street 2:SUITE 120
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1969
Practice Address - Country:US
Practice Address - Phone:415-499-0278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2020-04-10
Deactivation Date:2019-08-07
Deactivation Code:
Reactivation Date:2020-04-10
Provider Licenses
StateLicense IDTaxonomies
CA338752251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic