Provider Demographics
NPI:1790380970
Name:LEON, JESSE TRISTIAN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:TRISTIAN
Last Name:LEON
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CARMELLO DR
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-3025
Mailing Address - Country:US
Mailing Address - Phone:732-991-6678
Mailing Address - Fax:
Practice Address - Street 1:5 CARMELLO DR
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08817-3025
Practice Address - Country:US
Practice Address - Phone:732-991-6678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT002817002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer