MEDICARE: JANE HENDERSON EVERSOLE PT, MA

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	PT 7395	CA

General Provider Information

NPI Number	:	1730177908
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANE HENDERSON EVERSOLE PT, MA

Provider Business Mailing Address
First Line	:	18883 MASTERSON PL
Second Line	:
City	:	CASTRO VALLEY
State	:	CA
Zip	:	94552-5083
Country	:	US
Telephone Number	:	510-538-2586
Fax Number	:

Provider Business Practice Location Address
First Line	:	19845 LAKE CHABOT RD
Second Line	:	SUITE 205
City	:	CASTRO VALLEY
State	:	CA
Zip	:	94546-4055
Country	:	US
Telephone Number	:	510-538-9558
Fax Number	:	510-538-7017

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

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	07/08/2007

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