Provider Demographics
NPI:1225680788
Name:GAQUING, JESUS JR (PT)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:GAQUING
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3380 N WINDSONG DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-2262
Mailing Address - Country:US
Mailing Address - Phone:928-759-6545
Mailing Address - Fax:
Practice Address - Street 1:3380 N WINDSONG DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2262
Practice Address - Country:US
Practice Address - Phone:928-759-6545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070019825225100000X
AZLPT-011160225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist