Provider Demographics
NPI:1154966919
Name:DIZON, JESIREE MAE (PT)
Entity type:Individual
Prefix:
First Name:JESIREE MAE
Middle Name:
Last Name:DIZON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N ROBERTSON BLVD
Mailing Address - Street 2:STE 301
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-6001
Mailing Address - Country:US
Mailing Address - Phone:310-273-8256
Mailing Address - Fax:310-273-8542
Practice Address - Street 1:94-216 FARRINGTON HWY # A-102
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-1922
Practice Address - Country:US
Practice Address - Phone:808-600-9148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299906225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist