Basic Information
| Provider Information | |||||||||
| NPI: | 1659519809 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | CLAIRE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WHITE | ||||||||
| OtherFirstName: | JEANNIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 17860 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921777860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007876787 | ||||||||
| FaxNumber: | 8007876762 | ||||||||
| Practice Location | |||||||||
| Address1: | 4655 RUFFNER STREET | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921112275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007876787 | ||||||||
| FaxNumber: | 8007876762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2009 | ||||||||
| LastUpdateDate: | 01/27/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | AT2573 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.