Provider Demographics
NPI:1639768203
Name:MENDOZA, JESUS ALBERTO JR
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:ALBERTO
Last Name:MENDOZA
Suffix:JR
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 1:141 BROUGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3930
Mailing Address - Country:US
Mailing Address - Phone:862-333-8800
Mailing Address - Fax:
Practice Address - Street 1:141 BROUGHTON AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3930
Practice Address - Country:US
Practice Address - Phone:862-333-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJM251640161010122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer