Provider Demographics
NPI:1063763787
Name:JEZREEL, DANIEL SUKU (PT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:SUKU
Last Name:JEZREEL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:SUKUAMR
Other - Middle Name:
Other - Last Name:ARUMUGAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3122 ARGENTO PL
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-4357
Mailing Address - Country:US
Mailing Address - Phone:512-516-3466
Mailing Address - Fax:
Practice Address - Street 1:3122 ARGENTO PL
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-4357
Practice Address - Country:US
Practice Address - Phone:512-516-3466
Practice Address - Fax:855-855-5188
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-20
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12736002251G0304X
IN05009156A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics