MEDICARE: JERICKSON CU PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	8681691-2401	UT

General Provider Information

NPI Number	:	1407287105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERICKSON CU PT

Provider Business Mailing Address
First Line	:	10 W 1ST NORTH ST
Second Line	:
City	:	MESQUITE
State	:	NV
Zip	:	89027-4741
Country	:	US
Telephone Number	:	702-327-1281
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 W 1ST NORTH ST
Second Line	:
City	:	MESQUITE
State	:	NV
Zip	:	89027-4741
Country	:	US
Telephone Number	:	702-327-1281
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2013
Last Update Date	:	12/05/2013

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Directions to “ JERICKSON CU PT” Practice Location

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