Provider Demographics
NPI:1881131118
Name:PHAN, JIMMY (PT, DPT)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
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 1:24422 AVENIDA DE LA CARLOTA STE 190
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3634
Mailing Address - Country:US
Mailing Address - Phone:949-340-6927
Mailing Address - Fax:
Practice Address - Street 1:24422 AVENIDA DE LA CARLOTA STE 190
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3634
Practice Address - Country:US
Practice Address - Phone:949-340-6927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2019-08-05
Deactivation Date:2017-12-06
Deactivation Code:
Reactivation Date:2017-12-26
Provider Licenses
StateLicense IDTaxonomies
CAPT2939522251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics