Provider Demographics
NPI:1497213144
Name:MERCADO, JESSE (OT)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:MERCADO
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 E GARDEN DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-3149
Mailing Address - Country:US
Mailing Address - Phone:630-768-5947
Mailing Address - Fax:
Practice Address - Street 1:561 E GARDEN DR UNIT B
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-3149
Practice Address - Country:US
Practice Address - Phone:630-768-5947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0004212225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist