Provider Demographics
NPI:1831638188
Name:CUEVAS, JESSICA KARINA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KARINA
Last Name:CUEVAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13284 WILLIS RD
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-7790
Mailing Address - Country:US
Mailing Address - Phone:801-879-2086
Mailing Address - Fax:
Practice Address - Street 1:13284 WILLIS RD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-7790
Practice Address - Country:US
Practice Address - Phone:801-879-2086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT190344465172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver