Provider Demographics
NPI:1760785117
Name:DEJESUS, NICHOLAS
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:DEJESUS
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 1:147 NORMAN ST
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-5003
Mailing Address - Country:US
Mailing Address - Phone:413-736-8329
Mailing Address - Fax:413-746-4270
Practice Address - Street 1:120 MAPLE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-2203
Practice Address - Country:US
Practice Address - Phone:413-846-0445
Practice Address - Fax:413-846-0447
Is Sole Proprietor?:No
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1303295 (MH)Medicaid
MA1307576 (SA)Medicaid
M18463OtherBC / BS
MA1307576 (SA)Medicaid