Provider Demographics
NPI:1962871145
Name:RAVELY, JENNIFER (PTA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RAVELY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27299 STONEHURST DR
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92585-3419
Mailing Address - Country:US
Mailing Address - Phone:909-772-3648
Mailing Address - Fax:951-359-2096
Practice Address - Street 1:27299 STONEHURST DR
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92585-3419
Practice Address - Country:US
Practice Address - Phone:909-772-3648
Practice Address - Fax:951-359-2096
Is Sole Proprietor?:No
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT8385225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant