MEDICARE: JESSE RENO

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
1	225100000X	Physical Therapist	LPT-32584	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LPT-32584	OTHER	AZ	ARIZONA STATE BOARD OF PHYSICAL THERAPY

General Provider Information

NPI Number	:	1528782810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE RENO

Provider Business Mailing Address
First Line	:	2404 N STOCKTON HILL RD STE K
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86401-4184
Country	:	US
Telephone Number	:	928-440-6880
Fax Number	:	928-529-5036

Provider Business Practice Location Address
First Line	:	2404 N STOCKTON HILL RD STE K
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86401-4184
Country	:	US
Telephone Number	:	928-440-6880
Fax Number	:	928-529-5036

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2022
Last Update Date	:	09/29/2022

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Directions to “ JESSE RENO ” Practice Location

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