MEDICARE: JESSICA L SUPER PT, DPT, CSCS

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	PT35434	CA

General Provider Information

NPI Number	:	1801036819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA L SUPER PT, DPT, CSCS

Provider Business Mailing Address
First Line	:	44651 VILLAGE CT STE 120
Second Line	:
City	:	PALM DESERT
State	:	CA
Zip	:	92260-3823
Country	:	US
Telephone Number	:	760-501-6655
Fax Number	:	760-262-3773

Provider Business Practice Location Address
First Line	:	44651 VILLAGE CT STE 120
Second Line	:
City	:	PALM DESERT
State	:	CA
Zip	:	92260-3823
Country	:	US
Telephone Number	:	760-501-6655
Fax Number	:	760-262-3773

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

Provider Enumeration Date	:	03/03/2009
Last Update Date	:	03/02/2016

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