Provider Demographics
NPI:1285390633
Name:RICKS, JAYSON A (LMT)
Entity type:Individual
Prefix:
First Name:JAYSON
Middle Name:A
Last Name:RICKS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4228 PALMERO BLVD
Mailing Address - Street 2:
Mailing Address - City:VIEW PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90008-4422
Mailing Address - Country:US
Mailing Address - Phone:323-216-7978
Mailing Address - Fax:
Practice Address - Street 1:8590 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-2354
Practice Address - Country:US
Practice Address - Phone:323-216-7978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11431225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty