Provider Demographics
NPI:1508314428
Name:SWANN, JESSE (DPT)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:SWANN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 HWY 314 SW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-9600
Mailing Address - Country:US
Mailing Address - Phone:505-866-0055
Mailing Address - Fax:505-866-0057
Practice Address - Street 1:1220 CAMINO DEL LLANO
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-2727
Practice Address - Country:US
Practice Address - Phone:505-861-1200
Practice Address - Fax:505-861-1220
Is Sole Proprietor?:No
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4915225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist