Healthcare Provider Details

I. General information

NPI: 1386575553
Provider Name (Legal Business Name): JENNIFER CAROTHERS-LISKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3045 SANTIAGO ST
SAN FRANCISCO CA
94116-1526
US

IV. Provider business mailing address

6125 MARSHALL ST
OAKLAND CA
94608-2221
US

V. Phone/Fax

Practice location:
  • Phone: 415-759-2222
  • Fax: 415-750-8624
Mailing address:
  • Phone: 510-541-5148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number21521
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: