Basic Information
| Provider Information | |||||||||
| NPI: | 1023657053 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHUNG | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4860 ALMONDWOOD WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921302784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586499778 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 N PEPPER AVE | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923241819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095801000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2019 | ||||||||
| LastUpdateDate: | 12/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/20/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT17799 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.