Provider Demographics
NPI:1992810386
Name:SPURGEON, JENNIFER BANICO (MPT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:BANICO
Last Name:SPURGEON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:PANOPIO
Other - Last Name:BANICO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:1601 BARTON RD APT 2109
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5346
Mailing Address - Country:US
Mailing Address - Phone:909-798-3651
Mailing Address - Fax:
Practice Address - Street 1:11201 BENTON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92357-1000
Practice Address - Country:US
Practice Address - Phone:909-825-7084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29150225100000X
CA5402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant