Provider Demographics
NPI:1528782810
Name:RENO, JESSE
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:RENO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 N STOCKTON HILL RD STE K
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4184
Mailing Address - Country:US
Mailing Address - Phone:928-440-6880
Mailing Address - Fax:928-529-5036
Practice Address - Street 1:2404 N STOCKTON HILL RD STE K
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4184
Practice Address - Country:US
Practice Address - Phone:928-440-6880
Practice Address - Fax:928-529-5036
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-32584225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLPT-32584OtherARIZONA STATE BOARD OF PHYSICAL THERAPY