Healthcare Provider Details

I. General information

NPI: 1003383514
Provider Name (Legal Business Name): JESSICA J WU DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2018
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5190 GOVERNOR DR STE 107
SAN DIEGO CA
92122-2848
US

IV. Provider business mailing address

5190 GOVERNOR DR STE 107
SAN DIEGO CA
92122-2848
US

V. Phone/Fax

Practice location:
  • Phone: 858-304-6440
  • Fax:
Mailing address:
  • Phone: 858-452-0282
  • Fax: 858-452-6837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number304254
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: