Healthcare Provider Details

I. General information

NPI: 1912637992
Provider Name (Legal Business Name): JESSICA DIZON PT, DPT, NCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 05/27/2025
Certification Date: 01/11/2024
Deactivation Date: 02/14/2023
Reactivation Date: 05/01/2023

III. Provider practice location address

1301 20TH ST STE 300A
SANTA MONICA CA
90404-2050
US

IV. Provider business mailing address

1301 20TH ST STE 150
SANTA MONICA CA
90404-2050
US

V. Phone/Fax

Practice location:
  • Phone: 310-582-7111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number291629
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: