Healthcare Provider Details

I. General information

NPI: 1134976467
Provider Name (Legal Business Name): JESUS ZAVALA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2024
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N SAINT MARYS ST STE 1400
SAN ANTONIO TX
78205-3535
US

IV. Provider business mailing address

991 OAK CREEK DR
LOMBARD IL
60148-6408
US

V. Phone/Fax

Practice location:
  • Phone: 847-465-9556
  • Fax:
Mailing address:
  • Phone: 847-465-9556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-343885
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: