Provider Demographics
NPI:1770336406
Name:LY, JAMISON JOEL (PT)
Entity type:Individual
Prefix:DR
First Name:JAMISON JOEL
Middle Name:
Last Name:LY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:767 PUEBLO WAY
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-7842
Mailing Address - Country:US
Mailing Address - Phone:707-712-8107
Mailing Address - Fax:
Practice Address - Street 1:3 S LINDEN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-6407
Practice Address - Country:US
Practice Address - Phone:650-238-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302627225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist