Jesse Tellez Hernandez, NP-C
Individual provider
Active NPI
Nurse Practitioner · Fort Hall, ID
NPI 1184099558 · NPPES record last updated Mar 30, 2022
Key facts
- NPI
- 1184099558
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Nurse Practitioner 363L00000X
- License
- NP-1663A (ID)
- Practice address
- Building 70 Navajo Drive
Fort Hall, ID 83203
- Phone
- (208) 478-3987
- Fax
- (208) 478-4040
- NPI assigned
- Dec 10, 2015
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 4
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
Owned or controlled facilities with NPI records 3
Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in ID, TX
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
All facility ownership & control disclosures 3
Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.
| Facility | Type | Role | Since |
|---|
Community Family Clinic
Idaho Falls, ID · CCN 131829 |
Federally qualified health center |
Corporate Director |
Aug 29, 2020 |
Community Family Clinic
Blackfoot, ID · CCN 131831 |
Federally qualified health center |
Corporate Director |
Aug 29, 2020 |
Community Family Clinic
Rigby, ID · CCN 131045 |
Federally qualified health center |
Corporate Director |
Aug 29, 2020 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|
| I20181217003059 |
ID |
Practitioner - Nurse Practitioner |
5395080543 |
|
| I20190619002042 |
TX |
Practitioner - Nurse Practitioner |
5395080543 |
Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|
| 37988 | ID | MD | Mental Health Counselor |
| NP-1663A | ID | MD | Nurse Practitioner |
Practice roles
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|
| Nurse Practitioner |
363L00000X |
NP-1663A |
ID |
Yes |
Addresses
Primary practice location
Building 70 Navajo Drive
Fort Hall, ID 83203
Mailing address
PO Box 4414
Pocatello, ID 83205-4414
Phone (208) 219-9927
Other identifiers
| Identifier | Type | State | Issuer |
|---|
| NP-1663A | Other | ID | PROFESSIONAL LICENSE |
| 11948571-4405 | Other | UT | PROFESSIONAL LICENSE |
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 30, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.
Verify at the official NPI Registry.