Healthcare Provider Details

I. General information

NPI: 1770401440
Provider Name (Legal Business Name): JESUS CORONA PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 A ST
ANTIOCH CA
94509-2327
US

IV. Provider business mailing address

632 RICE ST
BRENTWOOD CA
94513-8312
US

V. Phone/Fax

Practice location:
  • Phone: 925-757-8787
  • Fax:
Mailing address:
  • Phone: 925-375-7243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number54798
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: