Provider Demographics
NPI:1568044253
Name:BALDERAS, JAZMIN (OTR/L)
Entity type:Individual
Prefix:
First Name:JAZMIN
Middle Name:
Last Name:BALDERAS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 BOMBAY AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-3514
Mailing Address - Country:US
Mailing Address - Phone:972-391-3550
Mailing Address - Fax:
Practice Address - Street 1:6168 BENTRIDGE DR
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-2615
Practice Address - Country:US
Practice Address - Phone:817-479-7019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX124630225X00000X
CAOT21525225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
15002128OtherCAQH PROVIEW