Provider Demographics
NPI:1619300530
Name:DE JESUS WELLNESS GROUP, P.C
Entity Type:Organization
Organization Name:DE JESUS WELLNESS GROUP, P.C
Other - Org Name:DE JESUS FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROWENA
Authorized Official - Middle Name:M
Authorized Official - Last Name:DE JESUS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:570-708-2228
Mailing Address - Street 1:298 ROCK GLEN RD
Mailing Address - Street 2:
Mailing Address - City:SUGARLOAF
Mailing Address - State:PA
Mailing Address - Zip Code:18249-3211
Mailing Address - Country:US
Mailing Address - Phone:570-708-2228
Mailing Address - Fax:570-708-2039
Practice Address - Street 1:298 ROCK GLEN RD
Practice Address - Street 2:
Practice Address - City:SUGARLOAF
Practice Address - State:PA
Practice Address - Zip Code:18249-3211
Practice Address - Country:US
Practice Address - Phone:570-708-2228
Practice Address - Fax:570-708-2039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-14
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC004270L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50087OtherMEDICARE TIN
PA583383OtherMEDICARE PTAN