Provider Demographics
NPI:1427623693
Name:PRIDGEN, JEFFREY SCOTT
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:SCOTT
Last Name:PRIDGEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 COLONIAL CT
Mailing Address - Street 2:
Mailing Address - City:DISCOVERY BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94505-9216
Mailing Address - Country:US
Mailing Address - Phone:925-642-1927
Mailing Address - Fax:
Practice Address - Street 1:705 TRANCAS ST
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-3014
Practice Address - Country:US
Practice Address - Phone:707-255-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51185225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant