Provider Demographics
NPI:1184099558
Name:TELLEZ HERNANDEZ, JESSE (NP-C)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:
Last Name:TELLEZ HERNANDEZ
Suffix:
Gender:M
Credentials:NP-C
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 4414
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4414
Mailing Address - Country:US
Mailing Address - Phone:208-219-9927
Mailing Address - Fax:
Practice Address - Street 1:BUILDING 70 NAVAJO DRIVE
Practice Address - Street 2:
Practice Address - City:FORT HALL
Practice Address - State:ID
Practice Address - Zip Code:83203
Practice Address - Country:US
Practice Address - Phone:208-478-3987
Practice Address - Fax:208-478-4040
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1663A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDNP-1663AOtherPROFESSIONAL LICENSE
UT11948571-4405OtherPROFESSIONAL LICENSE