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General NPI Number Information
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NPI Number | 1033756614
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Entity Type | Individual
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Provider Name | JERICK RICHARD PETERSON PTA
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Gender | Male
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Dates
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Enumeration Date | 12/03/2019
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Last Update Date | 12/03/2019
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Provider Practice Location Address
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Address Line | 1220 HUNTINGTON DR
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City | DUARTE
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State | CA
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Zip | 91010-2477
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Country | US
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Telephone | 626-359-6618
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Fax |
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Provider Business Mailing Address
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Address Line | 527 N AZUSA AVE # 179
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City | COVINA
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State | CA
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Zip | 91722-3502
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA48839
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License Number State | CA
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