Provider Demographics
NPI:1376679373
Name:ADDESSO, JACK LOUIS (RSA)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:LOUIS
Last Name:ADDESSO
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Gender:M
Credentials:RSA
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Mailing Address - Street 1:7324 SOUTHWEST FREEWAY
Mailing Address - Street 2:SUITE 1550
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77074
Mailing Address - Country:US
Mailing Address - Phone:713-779-9800
Mailing Address - Fax:713-779-9813
Practice Address - Street 1:7324 SOUTHWEST FREEWAY
Practice Address - Street 2:SUITE 1550
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-2053
Practice Address - Country:US
Practice Address - Phone:713-779-9800
Practice Address - Fax:713-779-9813
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2018-10-04
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Provider Licenses
StateLicense IDTaxonomies
IL238.000021246ZC0007X, 246ZS0410X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL238.000021OtherREGISTERED SURGICAL ASST.