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NPI Code Detail

MEDICARE: MRS. JESSICA CRETTAZ GOUDY

MEDICARE: MRS. JESSICA CRETTAZ GOUDY
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
1225400000XRehabilitation Practitioner

General Provider Information

NPI Number : 1114356391
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. JESSICA CRETTAZ GOUDY
Provider Business Mailing Address
First Line : 2364 GARGANEY AVE
Second Line :
City : NORTH LAS VEGAS
State : NV
Zip : 89084-3781
Country : US
Telephone Number : 503-830-7595
Fax Number :
Provider Business Practice Location Address
First Line : 2364 GARGANEY AVE
Second Line :
City : NORTH LAS VEGAS
State : NV
Zip : 89084-3781
Country : US
Telephone Number : 503-830-7595
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/07/2013
Last Update Date : 11/07/2013

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