Provider Demographics
NPI:1982372827
Name:BECERRA MORA, JESUS
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:BECERRA MORA
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 1:5665 HOOVER RD
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-9280
Mailing Address - Country:US
Mailing Address - Phone:614-539-6574
Mailing Address - Fax:
Practice Address - Street 1:5289 FRISCO DR.
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026
Practice Address - Country:US
Practice Address - Phone:614-999-6957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-04
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OH101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty