MEDICARE: JENNIFER ENRIQUEZ-JOHNSON P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	21496	CA

General Provider Information

NPI Number	:	1205942331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER ENRIQUEZ-JOHNSON P.T.

Provider Business Mailing Address
First Line	:	12300 MONTECITO RD
Second Line	:	3
City	:	SEAL BEACH
State	:	CA
Zip	:	90740-2743
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2401 E WARDLOW RD
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-5309
Country	:	US
Telephone Number	:	562-593-5817
Fax Number	:	562-982-6735

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	07/08/2007

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