Provider Demographics
NPI:1619650991
Name:OTERO-NIEVES, JEAN C
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:C
Last Name:OTERO-NIEVES
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 1:1514 SANDALWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:TX
Mailing Address - Zip Code:75409-4218
Mailing Address - Country:US
Mailing Address - Phone:787-516-9044
Mailing Address - Fax:
Practice Address - Street 1:14651 DALLAS PKWY STE 200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-8856
Practice Address - Country:US
Practice Address - Phone:866-919-3240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-11
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2143026225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant