Provider Demographics
NPI:1184990368
Name:DEJESUS-ROLENSON, JOSE MIGUEL (DO)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:MIGUEL
Last Name:DEJESUS-ROLENSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 VETERANS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-9586
Mailing Address - Country:US
Mailing Address - Phone:740-395-8090
Mailing Address - Fax:740-395-8197
Practice Address - Street 1:1000 VETERANS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-9586
Practice Address - Country:US
Practice Address - Phone:740-395-8090
Practice Address - Fax:740-395-8197
Is Sole Proprietor?:No
Enumeration Date:2012-04-01
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.012543207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0197993Medicaid