Provider Demographics
NPI:1023610854
Name:DIAB, JESSICA (PT,DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DIAB
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 PONY EXPRESS RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2780
Mailing Address - Country:US
Mailing Address - Phone:909-519-1672
Mailing Address - Fax:
Practice Address - Street 1:309 PONY EXPRESS RD
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2780
Practice Address - Country:US
Practice Address - Phone:909-519-1672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299382225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist