Provider Demographics
NPI:1528412780
Name:BINGHAM, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:BINGHAM
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:N14010 DEPAS LANE
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:MI
Mailing Address - Zip Code:49896
Mailing Address - Country:US
Mailing Address - Phone:906-399-6748
Mailing Address - Fax:
Practice Address - Street 1:N14010 DEPAS LN
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:MI
Practice Address - Zip Code:49896
Practice Address - Country:US
Practice Address - Phone:906-399-6748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR09238225200000X
TX2117208225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant