Provider Demographics
NPI:1356199061
Name:DE JESUS, JOHANNY
Entity type:Individual
Prefix:
First Name:JOHANNY
Middle Name:
Last Name:DE JESUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-4357
Mailing Address - Country:US
Mailing Address - Phone:781-353-1704
Mailing Address - Fax:
Practice Address - Street 1:60 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-4357
Practice Address - Country:US
Practice Address - Phone:781-353-1704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-08
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician