Healthcare Provider Details

I. General information

NPI: 1508445834
Provider Name (Legal Business Name): JEWEL JEDD CUISON LAZO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 E ROMIE LN
SALINAS CA
93901-4208
US

IV. Provider business mailing address

928 BIG BEAR CT
MILPITAS CA
95035-6954
US

V. Phone/Fax

Practice location:
  • Phone: 831-424-8072
  • Fax:
Mailing address:
  • Phone: 408-807-2759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number51061
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: