Provider Demographics
NPI:1619910742
Name:IRWIN, JESSE D (ATC)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:D
Last Name:IRWIN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 ASHWOOD DR
Mailing Address - Street 2:APARTMENT 7
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-4691
Mailing Address - Country:US
Mailing Address - Phone:573-230-6703
Mailing Address - Fax:
Practice Address - Street 1:1000 W 10TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2905
Practice Address - Country:US
Practice Address - Phone:573-230-6703
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050122672255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer