Healthcare Provider Details

I. General information

NPI: 1740710805
Provider Name (Legal Business Name): JESSE SUTTON OT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5914 QUAIL RIDGE AVE
HASTINGS NE
68901-9101
US

IV. Provider business mailing address

5914 QUAIL RIDGE AVE
HASTINGS NE
68901-9101
US

V. Phone/Fax

Practice location:
  • Phone: 308-215-0154
  • Fax: 402-463-2062
Mailing address:
  • Phone: 308-215-0154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2133
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: