Provider Demographics
NPI:1194434118
Name:WANG, JEFFREY GARY (DPT)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:GARY
Last Name:WANG
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 1:1460 DREW AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-4856
Mailing Address - Country:US
Mailing Address - Phone:530-753-9011
Mailing Address - Fax:530-753-9021
Practice Address - Street 1:1460 DREW AVE STE 200
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95618-4856
Practice Address - Country:US
Practice Address - Phone:530-753-9011
Practice Address - Fax:530-753-9021
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA303192225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist