Provider Demographics
NPI:1902300973
Name:BISSANI, JACLYN JULE (DPT)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:JULE
Last Name:BISSANI
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 VIA MEDICI
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-5838
Mailing Address - Country:US
Mailing Address - Phone:408-506-8595
Mailing Address - Fax:
Practice Address - Street 1:900 MOUNTAIN RANCH RD
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249-9713
Practice Address - Country:US
Practice Address - Phone:209-754-3823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-22
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT293921225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist