Provider Demographics
NPI:1245672179
Name:DE JESUS, TIFFANY A (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:A
Last Name:DE JESUS
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6831 FOX LANDING WAY APT 642
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-7631
Mailing Address - Country:US
Mailing Address - Phone:908-930-2725
Mailing Address - Fax:
Practice Address - Street 1:501 W WILLIAMS ST UNIT 346
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-1998
Practice Address - Country:US
Practice Address - Phone:908-930-2725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018141-1225X00000X
NC15111225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist