Provider Demographics
NPI:1902505910
Name:SMITH, JESSE STALLWORTH (DPT)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:STALLWORTH
Last Name:SMITH
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 1:4031 IDAHO ST UNIT F
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-2562
Mailing Address - Country:US
Mailing Address - Phone:619-482-3000
Mailing Address - Fax:619-482-3001
Practice Address - Street 1:1392 E PALOMAR ST STE 503
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91913-1895
Practice Address - Country:US
Practice Address - Phone:619-482-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-28
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048805-012251X0800X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic