Healthcare Provider Details

I. General information

NPI: 1891525093
Provider Name (Legal Business Name): JACOB T OGDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2024
Last Update Date: 08/03/2024
Certification Date: 08/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26522 LA ALAMEDA SUITE 100
MISSION VIEJO CA
92691-8579
US

IV. Provider business mailing address

26522 LA ALAMEDA STE 100
MISSION VIEJO CA
92691-8579
US

V. Phone/Fax

Practice location:
  • Phone: 949-582-2555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number306476
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: