Provider Demographics
NPI:1194105924
Name:MENDOZA, JERON (DPT)
Entity type:Individual
Prefix:
First Name:JERON
Middle Name:
Last Name:MENDOZA
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:PO BOX 715868
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19171-2626
Mailing Address - Country:US
Mailing Address - Phone:804-915-1910
Mailing Address - Fax:
Practice Address - Street 1:15195 HEATHCOTE BLVD STE 334
Practice Address - Street 2:
Practice Address - City:HAYMARKET
Practice Address - State:VA
Practice Address - Zip Code:20169-6244
Practice Address - Country:US
Practice Address - Phone:703-334-5405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-07
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052094662251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic