Provider Demographics
NPI:1427830850
Name:MEDINA, JESUS HUMBERTO JR (LAT)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:HUMBERTO
Last Name:MEDINA
Suffix:JR
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 CELUM RD
Mailing Address - Street 2:
Mailing Address - City:CLINT
Mailing Address - State:TX
Mailing Address - Zip Code:79836-4903
Mailing Address - Country:US
Mailing Address - Phone:191-547-8123
Mailing Address - Fax:
Practice Address - Street 1:1050 CHICKEN RANCH RD
Practice Address - Street 2:
Practice Address - City:SAN ELIZARIO
Practice Address - State:TX
Practice Address - Zip Code:79849
Practice Address - Country:US
Practice Address - Phone:915-872-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT29302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer