Provider Demographics
NPI:1902087299
Name:UNDERWOOD, JEANNE (PTA, ATC)
Entity Type:Individual
Prefix:MS
First Name:JEANNE
Middle Name:
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:PTA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23430 HAWTHORNE BLVD
Mailing Address - Street 2:BLDG. 3, SUITE 105
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4720
Mailing Address - Country:US
Mailing Address - Phone:310-791-3812
Mailing Address - Fax:310-373-4686
Practice Address - Street 1:23430 HAWTHORNE BLVD
Practice Address - Street 2:BLDG. 3, SUITE 105
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4720
Practice Address - Country:US
Practice Address - Phone:310-791-3812
Practice Address - Fax:310-373-4686
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 3805225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant