Basic Information
| Provider Information | |||||||||
| NPI: | 1801514153 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIMONE | ||||||||
| FirstName: | JERICHO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14100 SAN PEDRO AVE STE 412 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782322009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1098119752 | ||||||||
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| Practice Location | |||||||||
| Address1: | 24200 IH 10 W STE 109 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782571150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102639443 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2022 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-22-231989 | TX | N | 106E00000X | RBT-22-231989 | TX | Y | 106S00000X | N |
No ID Information.