Provider Demographics
NPI:1659739050
Name:VEGA DE JESUS, RAMON
Entity Type:Individual
Prefix:DR
First Name:RAMON
Middle Name:
Last Name:VEGA DE JESUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CHRISTMAS TREE HL
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:CT
Mailing Address - Zip Code:06019-2127
Mailing Address - Country:US
Mailing Address - Phone:209-484-8045
Mailing Address - Fax:
Practice Address - Street 1:45 WADSWORTH ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-7108
Practice Address - Country:US
Practice Address - Phone:860-527-1124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-01
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003520101YP2500X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1245324516Medicaid