MEDICARE: JODELYN TEOFILA ETTLIN PTA

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	225200000X	Physical Therapy Assistant	AT-9120	CA

General Provider Information

NPI Number	:	1508284886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JODELYN TEOFILA ETTLIN PTA

Provider Business Mailing Address
First Line	:	1244 DE MEO ST
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95407-5924
Country	:	US
Telephone Number	:	707-480-7789
Fax Number	:

Provider Business Practice Location Address
First Line	:	6174 STATE FARM DR
Second Line	:
City	:	ROHNERT PARK
State	:	CA
Zip	:	94928-2135
Country	:	US
Telephone Number	:	707-480-7789
Fax Number	:

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

Provider Enumeration Date	:	04/03/2014
Last Update Date	:	04/03/2014

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