Provider Demographics
NPI:1154995967
Name:DAVIS, JESSICA TAMARA (DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:TAMARA
Last Name:DAVIS
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4608 MARDI GRAS ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92057-5108
Mailing Address - Country:US
Mailing Address - Phone:760-622-3875
Mailing Address - Fax:
Practice Address - Street 1:700 GARDEN VIEW CT STE 103
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2478
Practice Address - Country:US
Practice Address - Phone:760-632-6942
Practice Address - Fax:760-632-6819
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT300184174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA300184OtherPT LICENSE