Provider Demographics
NPI:1821326356
Name:FERNANDEZ, JESSE (DPT)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:DR
Other - First Name:JESSE
Other - Middle Name:
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPT
Mailing Address - Street 1:5024 DORSEY HALL DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-7869
Mailing Address - Country:US
Mailing Address - Phone:410-740-1047
Mailing Address - Fax:
Practice Address - Street 1:5024 DORSEY HALL DR
Practice Address - Street 2:SUITE 103
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7869
Practice Address - Country:US
Practice Address - Phone:410-740-1047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23114174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist