Provider Demographics
NPI:1821711169
Name:DE JESUS, JOHANNA CAMILLE (FNP-C)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:CAMILLE
Last Name:DE JESUS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14940 CHERRY GROVE CT
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6115
Mailing Address - Country:US
Mailing Address - Phone:626-377-0642
Mailing Address - Fax:
Practice Address - Street 1:14940 CHERRY GROVE CT
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6115
Practice Address - Country:US
Practice Address - Phone:626-377-0642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-21
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1119112363L00000X
OK211096363L00000X
CA95013358363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily