Provider Demographics
NPI:1952899502
Name:SU, JEFFREY (DPT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:SU
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 WHITNEY DR
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-4429
Mailing Address - Country:US
Mailing Address - Phone:626-366-6441
Mailing Address - Fax:
Practice Address - Street 1:2640 WHITNEY DR
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-4429
Practice Address - Country:US
Practice Address - Phone:626-366-6441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA294376225100000X
CAPT2943762081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT294376OtherPHYSICAL THERAPY