MEDICARE: MR. JESSIE VELAZQUEZ I

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	2255A2300X	Athletic Trainer		TX
2	390200000X	Student in an Organized Health Care Education/Training Program		TX

General Provider Information

NPI Number	:	1841772910
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JESSIE VELAZQUEZ I

Provider Business Mailing Address
First Line	:	1921 TISINGER AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75228-2108
Country	:	US
Telephone Number	:	469-767-1409
Fax Number	:

Provider Business Practice Location Address
First Line	:	1921 TISINGER AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75228-2108
Country	:	US
Telephone Number	:	469-767-1409
Fax Number	:

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

Provider Enumeration Date	:	09/05/2018
Last Update Date	:	09/05/2018

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Directions to “ MR. JESSIE VELAZQUEZ I ” Practice Location

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