Provider Demographics
NPI:1831875129
Name:GUEVARRA, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:GUEVARRA
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 1:505 BELLOWS CT
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1871
Mailing Address - Country:US
Mailing Address - Phone:909-282-5357
Mailing Address - Fax:
Practice Address - Street 1:4300 GREEN RIVER RD STE 114
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92878-2306
Practice Address - Country:US
Practice Address - Phone:951-382-4238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-22
Last Update Date:2023-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52378225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant