Provider Demographics
NPI:1720422983
Name:LA ROSA, JETHRO PAYNE DE VEGA
Entity Type:Individual
Prefix:
First Name:JETHRO PAYNE
Middle Name:DE VEGA
Last Name:LA ROSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39210 STATE ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1456
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:39210 STATE ST
Practice Address - Street 2:SUITE 202
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1456
Practice Address - Country:US
Practice Address - Phone:510-790-9480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant