Provider Demographics
NPI:1659815801
Name:ONTIVEROZ, JESUS
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:ONTIVEROZ
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 1:4646 W JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:ECORSE
Mailing Address - State:MI
Mailing Address - Zip Code:48229-1418
Mailing Address - Country:US
Mailing Address - Phone:313-622-9827
Mailing Address - Fax:
Practice Address - Street 1:4646 W JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:ECORSE
Practice Address - State:MI
Practice Address - Zip Code:48229-1418
Practice Address - Country:US
Practice Address - Phone:313-622-9827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC-02164101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)