Provider Demographics
NPI:1730386129
Name:JEDLICKA, ANGELINA LEE (PT)
Entity type:Individual
Prefix:MRS
First Name:ANGELINA
Middle Name:LEE
Last Name:JEDLICKA
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 1:3314 DURHAM CT
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504-1600
Mailing Address - Country:US
Mailing Address - Phone:818-953-5157
Mailing Address - Fax:
Practice Address - Street 1:1336 N EDGEMONT ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5912
Practice Address - Country:US
Practice Address - Phone:323-783-5499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT11250174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT11250OtherPHYSICAL THERAPIST