Provider Demographics
NPI:1225249642
Name:DEJESUS, MARK (OT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:DEJESUS
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019 MEADOWLARK LN
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-6127
Mailing Address - Country:US
Mailing Address - Phone:620-341-9549
Mailing Address - Fax:
Practice Address - Street 1:2700 WEST 30TH AVENUE
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801
Practice Address - Country:US
Practice Address - Phone:620-343-9285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1701739225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist