Provider Demographics
NPI:1538635982
Name:JESTROVICH, CASEY RYKO (CNIM, R EEG T)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:RYKO
Last Name:JESTROVICH
Suffix:
Gender:M
Credentials:CNIM, R EEG T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2318 HALL AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-6234
Mailing Address - Country:US
Mailing Address - Phone:303-886-6641
Mailing Address - Fax:
Practice Address - Street 1:2318 HALL AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-6234
Practice Address - Country:US
Practice Address - Phone:303-886-6641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO99-187-0511246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
COVAD450M96159OtherANTHEM BLUE CROSS/BLUE SHIELD