Provider Demographics
NPI:1679195168
Name:DE JESUS, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:DE JESUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 CALLE HOCONUCO
Mailing Address - Street 2:
Mailing Address - City:CANOVANAS
Mailing Address - State:PR
Mailing Address - Zip Code:00729-4317
Mailing Address - Country:US
Mailing Address - Phone:787-531-5180
Mailing Address - Fax:
Practice Address - Street 1:10 CALLE CASIA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-3200
Practice Address - Country:US
Practice Address - Phone:787-641-7582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR598224ZL0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224ZL0004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantLow VisionGroup - Single Specialty