Provider Demographics
NPI:1093295214
Name:HERNANDEZ, JESUS R (OT)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:R
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4423 JESSE BOWMAN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-5024
Mailing Address - Country:US
Mailing Address - Phone:210-338-5727
Mailing Address - Fax:
Practice Address - Street 1:8503 MYSTIC PARK
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78254-2544
Practice Address - Country:US
Practice Address - Phone:210-256-0906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109417225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist