Provider Demographics
NPI:1750904975
Name:HOLMES, DEJUAN XZAVIER
Entity type:Individual
Prefix:
First Name:DEJUAN
Middle Name:XZAVIER
Last Name:HOLMES
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 1:2622 SEXTANT AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HUENEME
Mailing Address - State:CA
Mailing Address - Zip Code:93041-1420
Mailing Address - Country:US
Mailing Address - Phone:760-264-6156
Mailing Address - Fax:
Practice Address - Street 1:2009 LAS ESTRELLAS CT
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-4070
Practice Address - Country:US
Practice Address - Phone:180-540-7453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF4739693106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician