Provider Demographics
NPI:1639589534
Name:BYRD, JESSE (LMT)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:BYRD
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 FLORIDA ST SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-4926
Mailing Address - Country:US
Mailing Address - Phone:505-633-8889
Mailing Address - Fax:
Practice Address - Street 1:820 FLORIDA ST SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-4926
Practice Address - Country:US
Practice Address - Phone:505-633-8889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6697225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist