Provider Demographics
NPI:1912632548
Name:CARLUCCI, JESSE DAVID (PTA)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:DAVID
Last Name:CARLUCCI
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:JESSE
Other - Middle Name:DAVID
Other - Last Name:CARLUCCI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:16912 TABLELAND TRL
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77385-2010
Mailing Address - Country:US
Mailing Address - Phone:518-852-4284
Mailing Address - Fax:
Practice Address - Street 1:303 LANTERN BEND DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-2823
Practice Address - Country:US
Practice Address - Phone:518-852-4284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2110477208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation