Provider Demographics
NPI:1104676147
Name:LANDEROS, JESSICA LUPE (DPT)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LUPE
Last Name:LANDEROS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6214 W MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3801
Mailing Address - Country:US
Mailing Address - Phone:310-601-6090
Mailing Address - Fax:
Practice Address - Street 1:6214 W MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3801
Practice Address - Country:US
Practice Address - Phone:310-348-8464
Practice Address - Fax:310-348-8470
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT305569225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist