Provider Demographics
NPI:1407287105
Name:CU, JERICKSON (PT)
Entity Type:Individual
Prefix:
First Name:JERICKSON
Middle Name:
Last Name:CU
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 1:10 W 1ST NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:NV
Mailing Address - Zip Code:89027-4741
Mailing Address - Country:US
Mailing Address - Phone:702-327-1281
Mailing Address - Fax:
Practice Address - Street 1:10 W 1ST NORTH ST
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:NV
Practice Address - Zip Code:89027-4741
Practice Address - Country:US
Practice Address - Phone:702-327-1281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8681691-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist