Provider Demographics
NPI:1700169703
Name:NELSON, JOLENE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1423 EUCLID ST
Mailing Address - Street 2:APT. 2
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2742
Mailing Address - Country:US
Mailing Address - Phone:415-548-0703
Mailing Address - Fax:
Practice Address - Street 1:21615 HAWTHORNE BLVD
Practice Address - Street 2:200
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-6668
Practice Address - Country:US
Practice Address - Phone:310-371-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390672251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics