Provider Demographics
NPI:1831621481
Name:PEARSON, JESSE (CNMT)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:PEARSON
Suffix:
Gender:M
Credentials:CNMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2522 N FOX RUN CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-3605
Mailing Address - Country:US
Mailing Address - Phone:605-261-0294
Mailing Address - Fax:
Practice Address - Street 1:2522 N FOX RUN CT
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-3605
Practice Address - Country:US
Practice Address - Phone:605-261-0294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS22-02994247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist