Provider Demographics
NPI:1376106393
Name:DESION, JERUSALEM (LPC)
Entity Type:Individual
Prefix:
First Name:JERUSALEM
Middle Name:
Last Name:DESION
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 CAMINO CRESTA PL
Mailing Address - Street 2:
Mailing Address - City:HORIZON CITY
Mailing Address - State:TX
Mailing Address - Zip Code:79928-7496
Mailing Address - Country:US
Mailing Address - Phone:915-256-2102
Mailing Address - Fax:
Practice Address - Street 1:113 CAMINO CRESTA PL
Practice Address - Street 2:
Practice Address - City:HORIZON CITY
Practice Address - State:TX
Practice Address - Zip Code:79928-7496
Practice Address - Country:US
Practice Address - Phone:915-256-2102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16549101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148178001Medicaid