Provider Demographics
NPI:1134788953
Name:LOU, JESSE (MD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:LOU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S 11TH ST STE 8490
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4824
Mailing Address - Country:US
Mailing Address - Phone:215-503-6476
Mailing Address - Fax:
Practice Address - Street 1:19851 OBSERVATION DR STE 360
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-4141
Practice Address - Country:US
Practice Address - Phone:855-527-7246
Practice Address - Fax:866-229-5063
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT227637207LP2900X
MI4351044760208100000X
MDD0100095208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation