Healthcare Provider Details

I. General information

NPI: 1235604489
Provider Name (Legal Business Name): JEDD CUARESMA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 N GIBSON RD
HENDERSON NV
89014-6760
US

IV. Provider business mailing address

7224 PORTIA CT
LAS VEGAS NV
89113-0247
US

V. Phone/Fax

Practice location:
  • Phone: 702-558-6275
  • Fax: 702-856-3198
Mailing address:
  • Phone: 702-289-8048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3864
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: