Provider Demographics
NPI:1831655240
Name:BALDERAS, JESSE (PTA)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:BALDERAS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 CLUB LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:TX
Mailing Address - Zip Code:78382-7376
Mailing Address - Country:US
Mailing Address - Phone:361-463-9205
Mailing Address - Fax:
Practice Address - Street 1:920 E AVENUE L
Practice Address - Street 2:
Practice Address - City:SILSBEE
Practice Address - State:TX
Practice Address - Zip Code:77656-5014
Practice Address - Country:US
Practice Address - Phone:409-385-5571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2023208202C00000X, 225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical Examiner
Provider Identifiers
StateIdentifier IDID TypeIssuer
A63821026OtherTHERAPY
A63821026OtherREHAB