Healthcare Provider Details

I. General information

NPI: 1063887073
Provider Name (Legal Business Name): JUSTIN DAVID JETTE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2015
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10590 TOWN CENTER DR SUITE 100
RANCHO CUCAMONGA CA
91730-0360
US

IV. Provider business mailing address

10590 TOWN CENTER DR SUITE 100
RANCHO CUCAMONGA CA
91730-0360
US

V. Phone/Fax

Practice location:
  • Phone: 909-948-1124
  • Fax:
Mailing address:
  • Phone: 909-948-1124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number43441
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: