Provider Demographics
NPI:1467795278
Name:DE JESUS, WALKIRIA A (PD MS ED)
Entity Type:Individual
Prefix:
First Name:WALKIRIA
Middle Name:A
Last Name:DE JESUS
Suffix:
Gender:F
Credentials:PD MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2635 MEAD AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34771-7875
Mailing Address - Country:US
Mailing Address - Phone:917-557-5575
Mailing Address - Fax:
Practice Address - Street 1:18425 NW 2ND AVE PH 5
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33169-4524
Practice Address - Country:US
Practice Address - Phone:954-257-7473
Practice Address - Fax:877-578-5333
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS-1507103TS0200X
103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool