Provider Demographics
NPI:1841358231
Name:DUARTE, JESUS
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:DUARTE
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:PO BOX 50224
Mailing Address - Street 2:
Mailing Address - City:PARKS
Mailing Address - State:AZ
Mailing Address - Zip Code:86018-0224
Mailing Address - Country:US
Mailing Address - Phone:928-600-5544
Mailing Address - Fax:
Practice Address - Street 1:291 N. STEVENS LN.
Practice Address - Street 2:LOT 13
Practice Address - City:PARKS
Practice Address - State:AZ
Practice Address - Zip Code:86018
Practice Address - Country:US
Practice Address - Phone:928-600-5544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3887385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ738148OtherAHCCCS ID