Provider Demographics
NPI:1447799739
Name:DE JESUS, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
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 1:1310 SAN BERNARDINO RD STE 105
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4985
Mailing Address - Country:US
Mailing Address - Phone:909-429-2864
Mailing Address - Fax:
Practice Address - Street 1:1310 SAN BERNARDINO RD STE 105
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4985
Practice Address - Country:US
Practice Address - Phone:909-429-2864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-20
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA720787163WD0400X, 390200000X
CA95022332363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program