Healthcare Provider Details

I. General information

NPI: 1639664824
Provider Name (Legal Business Name): JEFFREY MARVIN JUE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2018
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11560 W PICO BLVD
LOS ANGELES CA
90064-1520
US

IV. Provider business mailing address

11560 W PICO BLVD
LOS ANGELES CA
90064-1520
US

V. Phone/Fax

Practice location:
  • Phone: 310-477-8285
  • Fax: 310-477-9642
Mailing address:
  • Phone: 310-477-8285
  • Fax: 310-477-9642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT295010
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: