Provider Demographics
NPI:1669694519
Name:ANDERSON, JONI (PT)
Entity type:Individual
Prefix:
First Name:JONI
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12239 MADRONA WAY
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-3506
Mailing Address - Country:US
Mailing Address - Phone:530-477-0868
Mailing Address - Fax:
Practice Address - Street 1:202 PROVIDENCE MINE RD
Practice Address - Street 2:SUITE 206
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-2947
Practice Address - Country:US
Practice Address - Phone:530-265-8100
Practice Address - Fax:530-265-8112
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT12356225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0PT123560Medicare PIN