Provider Demographics
NPI:1780232462
Name:TREJO, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:TREJO
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 1:3660 STATE HIGHWAY 132
Mailing Address - Street 2:
Mailing Address - City:COULTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95311-9722
Mailing Address - Country:US
Mailing Address - Phone:209-566-5559
Mailing Address - Fax:
Practice Address - Street 1:3660 STATE HIGHWAY 132
Practice Address - Street 2:
Practice Address - City:COULTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95311-9722
Practice Address - Country:US
Practice Address - Phone:209-566-5559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2095665559OtherVA BOWEL AND BLADDER