Provider Demographics
NPI:1508102070
Name:MENA, JESUS (MS)
Entity Type:Individual
Prefix:MR
First Name:JESUS
Middle Name:
Last Name:MENA
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 OHIO RD
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-4948
Mailing Address - Country:US
Mailing Address - Phone:239-645-3338
Mailing Address - Fax:
Practice Address - Street 1:6075 BATHEY LN
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34116-7536
Practice Address - Country:US
Practice Address - Phone:239-354-1408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-02
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL592206025Medicaid