Provider Demographics
NPI:1386011492
Name:TRESE, JAE
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:
Last Name:TRESE
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 1:249 E TABERNACLE ST
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-2978
Mailing Address - Country:US
Mailing Address - Phone:727-430-4940
Mailing Address - Fax:
Practice Address - Street 1:249 E TABERNACLE ST
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-2978
Practice Address - Country:US
Practice Address - Phone:727-430-4940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24925225200000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant