Provider Demographics
NPI:1659431617
Name:DE JESUS, FERDINAND C (PT/DPT, CCC-SLP)
Entity Type:Individual
Prefix:DR
First Name:FERDINAND
Middle Name:C
Last Name:DE JESUS
Suffix:
Gender:M
Credentials:PT/DPT, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13330 NOEL RD APT 338
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-5087
Mailing Address - Country:US
Mailing Address - Phone:914-886-8153
Mailing Address - Fax:
Practice Address - Street 1:13330 NOEL RD APT 338
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-5087
Practice Address - Country:US
Practice Address - Phone:914-886-8153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018598235Z00000X
NY009781-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02050508Medicaid
NY02050508Medicaid