Provider Demographics
NPI:1407153620
Name:HERRERA, JESUS (PT)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:HERRERA
Suffix:
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 1:12300 PELLICANO DR
Mailing Address - Street 2:SUITE B-2
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-6857
Mailing Address - Country:US
Mailing Address - Phone:915-494-2743
Mailing Address - Fax:915-860-4839
Practice Address - Street 1:12300 PELLICANO DR
Practice Address - Street 2:SUITE B-2
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-6857
Practice Address - Country:US
Practice Address - Phone:915-860-4838
Practice Address - Fax:915-860-4839
Is Sole Proprietor?:No
Enumeration Date:2011-02-24
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3919225100000X
TX1216579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1216579OtherTEXAS STATE LICENSE