Healthcare Provider Details

I. General information

NPI: 1457294027
Provider Name (Legal Business Name): JENNIFER WILLMES
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2026
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 COASTLAND AVE
SAN JOSE CA
95125-2516
US

IV. Provider business mailing address

2021 COASTLAND AVE
SAN JOSE CA
95125-2516
US

V. Phone/Fax

Practice location:
  • Phone: 415-310-5703
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number50757
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: