Healthcare Provider Details

I. General information

NPI: 1356256895
Provider Name (Legal Business Name): JESSICA WOODS RAFFERTY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA LENOR WOODS

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 EMERALD BAY RD
SOUTH LAKE TAHOE CA
96150-6413
US

IV. Provider business mailing address

1515 ORMSBY DR
SOUTH LAKE TAHOE CA
96150-7453
US

V. Phone/Fax

Practice location:
  • Phone: 530-542-2662
  • Fax: 530-542-2661
Mailing address:
  • Phone:
  • Fax: 760-264-4342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number48498
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: