MEDICARE: ELISE JAFFREZO PTLA

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	303615	CA

General Provider Information

NPI Number	:	1306541719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELISE JAFFREZO PTLA

Provider Business Mailing Address
First Line	:	1134 BLUEBELL DR
Second Line	:
City	:	LIVERMORE
State	:	CA
Zip	:	94551-1334
Country	:	US
Telephone Number	:	925-750-4966
Fax Number	:

Provider Business Practice Location Address
First Line	:	87 FENTON ST STE 106
Second Line	:
City	:	LIVERMORE
State	:	CA
Zip	:	94550-4159
Country	:	US
Telephone Number	:	925-373-9394
Fax Number	:

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

Provider Enumeration Date	:	04/04/2023
Last Update Date	:	04/04/2023

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