Provider Demographics
NPI:1992828065
Name:HOFACKET, JESSE WAYNE (PT)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:WAYNE
Last Name:HOFACKET
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7538
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88355-7538
Mailing Address - Country:US
Mailing Address - Phone:505-354-0514
Mailing Address - Fax:
Practice Address - Street 1:2600 N HIGHWAY 118
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:TX
Practice Address - Zip Code:79830-2002
Practice Address - Country:US
Practice Address - Phone:432-837-0220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1124225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist