Healthcare Provider Details

I. General information

NPI: 1285429654
Provider Name (Legal Business Name): JENNIE D PHOUTHAVONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LANTERN CREST WAY
SANTEE CA
92071-4775
US

IV. Provider business mailing address

13063 WIMBERLY SQ UNIT 115
SAN DIEGO CA
92128-6023
US

V. Phone/Fax

Practice location:
  • Phone: 619-312-0929
  • Fax:
Mailing address:
  • Phone: 619-994-3220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA48583
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: