Healthcare Provider Details

I. General information

NPI: 1992869366
Provider Name (Legal Business Name): JAYME HEATHER ANDERSON O'CONNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAYME ANDERSON

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SERENO DR
VALLEJO CA
94589-2441
US

IV. Provider business mailing address

975 SERENO DR
VALLEJO CA
94589-2441
US

V. Phone/Fax

Practice location:
  • Phone: 707-651-4782
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number22797
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: