Provider Demographics
NPI:1972623163
Name:DAVIDSON, JEANNIE ANN (PTA - CSMT)
Entity type:Individual
Prefix:MS
First Name:JEANNIE
Middle Name:ANN
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:PTA - CSMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6204 JARVIS AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-1213
Mailing Address - Country:US
Mailing Address - Phone:510-710-1122
Mailing Address - Fax:
Practice Address - Street 1:13939 E 14TH ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2613
Practice Address - Country:US
Practice Address - Phone:510-343-8300
Practice Address - Fax:510-343-8302
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT3096225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant