Provider Demographics
NPI:1851076905
Name:DE JESUS, JUAN
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name: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 1:10450 102ND ST
Mailing Address - Street 2:
Mailing Address - City:OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11417-2237
Mailing Address - Country:US
Mailing Address - Phone:929-354-1829
Mailing Address - Fax:
Practice Address - Street 1:10450 102ND ST
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11417-2237
Practice Address - Country:US
Practice Address - Phone:929-354-1829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator