Provider Demographics
NPI:1528728029
Name:EDMISTEN, JANIFER SNELL (PT)
Entity type:Individual
Prefix:DR
First Name:JANIFER
Middle Name:SNELL
Last Name:EDMISTEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JANIFER
Other - Middle Name:SNELL
Other - Last Name:KODAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19377 DE MARCO RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-6160
Mailing Address - Country:US
Mailing Address - Phone:951-500-6829
Mailing Address - Fax:
Practice Address - Street 1:8432 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-3206
Practice Address - Country:US
Practice Address - Phone:951-343-4539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-23
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT21466225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist