Provider Demographics
NPI:1154071264
Name:DE JESUS, LATAYA
Entity Type:Individual
Prefix:
First Name:LATAYA
Middle Name:
Last Name:DE JESUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-3247
Mailing Address - Country:US
Mailing Address - Phone:304-865-3600
Mailing Address - Fax:
Practice Address - Street 1:1212 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-3247
Practice Address - Country:US
Practice Address - Phone:304-865-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0031356363LF0000X
OH0000837405300000X
WV113014363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No405300000XOther Service ProvidersPrevention Professional