Provider Demographics
NPI:1447685722
Name:DE JESUS, CARMEN ROXANA
Entity type:Individual
Prefix:MS
First Name:CARMEN
Middle Name:ROXANA
Last Name:DE JESUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:ROXANA
Other - Last Name:DE JESUS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:BARBOSA 2021
Mailing Address - Street 2:VILLA PALMERAS
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00912-4243
Mailing Address - Country:US
Mailing Address - Phone:787-636-0235
Mailing Address - Fax:787-768-0565
Practice Address - Street 1:BARBOSA 2021
Practice Address - Street 2:VILLA PALMERAS
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00912-4243
Practice Address - Country:US
Practice Address - Phone:787-636-0235
Practice Address - Fax:787-768-0565
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR53721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR5372OtherSTATE LICENCES