Provider Demographics
NPI:1053739359
Name:BAUMGARTNER, JESSON
Entity type:Individual
Prefix:
First Name:JESSON
Middle Name:
Last Name:BAUMGARTNER
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 1:343 ELM ST STE 202
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-4538
Mailing Address - Country:US
Mailing Address - Phone:775-870-1480
Mailing Address - Fax:877-764-6351
Practice Address - Street 1:343 ELM ST STE 202
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4538
Practice Address - Country:US
Practice Address - Phone:775-870-1480
Practice Address - Fax:877-764-6351
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN59655208100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program