Provider Demographics
NPI:1467112904
Name:NORDSTROM, JESSE LEE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:LEE
Last Name:NORDSTROM
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 1:3220 TERRA BELLA DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-4751
Mailing Address - Country:US
Mailing Address - Phone:702-428-2399
Mailing Address - Fax:
Practice Address - Street 1:3220 TERRA BELLA DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-4751
Practice Address - Country:US
Practice Address - Phone:702-428-2399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-25
Last Update Date:2021-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV374U00000X374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty