Provider Demographics
NPI:1164965380
Name:MESA-DE JESUS, ELAYNE JOVANNA
Entity Type:Individual
Prefix:
First Name:ELAYNE
Middle Name:JOVANNA
Last Name:MESA-DE JESUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELAYNE
Other - Middle Name:JOVANNA
Other - Last Name:MESA ROSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2258 GRAND AVE BSMT B1
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-1536
Mailing Address - Country:US
Mailing Address - Phone:917-216-2574
Mailing Address - Fax:
Practice Address - Street 1:2258 GRAND AVE BSMT B1
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-1536
Practice Address - Country:US
Practice Address - Phone:917-216-2574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-19
Last Update Date:2016-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator