Provider Demographics
NPI:1912637992
Name:DIZON, JESSICA (PT, DPT, NCS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DIZON
Suffix:
Gender:F
Credentials:PT, DPT, NCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 20TH ST STE 150
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 20TH ST STE 300A
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2050
Practice Address - Country:US
Practice Address - Phone:310-582-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2024-01-11
Deactivation Date:2023-02-14
Deactivation Code:
Reactivation Date:2023-05-01
Provider Licenses
StateLicense IDTaxonomies
2251N0400X
CA291629225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology