Healthcare Provider Details

I. General information

NPI: 1053739359
Provider Name (Legal Business Name): JESSON BAUMGARTNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 ELM ST STE 202
RENO NV
89503-4538
US

IV. Provider business mailing address

343 ELM ST STE 202
RENO NV
89503-4538
US

V. Phone/Fax

Practice location:
  • Phone: 775-870-1480
  • Fax: 877-764-6351
Mailing address:
  • Phone: 775-870-1480
  • Fax: 877-764-6351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number59655
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: