Provider Demographics
NPI:1487013694
Name:MORENO, JESSICA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 BESSEMER DR STE B
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-5909
Mailing Address - Country:US
Mailing Address - Phone:915-629-7669
Mailing Address - Fax:915-629-7679
Practice Address - Street 1:1527 BROWN ST STE B
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-4737
Practice Address - Country:US
Practice Address - Phone:915-533-3511
Practice Address - Fax:915-533-3522
Is Sole Proprietor?:No
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1181090225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist