Provider Demographics
NPI:1003519240
Name:TREVINO, JESUS JACOB
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:JACOB
Last Name:TREVINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 MUSTANG CT
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-2086
Mailing Address - Country:US
Mailing Address - Phone:760-886-1963
Mailing Address - Fax:
Practice Address - Street 1:295 MUSTANG CT
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:CA
Practice Address - Zip Code:92251-2086
Practice Address - Country:US
Practice Address - Phone:760-886-1963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other