Provider Demographics
NPI:1871140350
Name:DEJESUS, ANTHONY DOUGLAS (SUDPT, CADC-R)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:DOUGLAS
Last Name:DEJESUS
Suffix:
Gender:M
Credentials:SUDPT, CADC-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16203 NE 32ND ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-3674
Mailing Address - Country:US
Mailing Address - Phone:347-988-2161
Mailing Address - Fax:
Practice Address - Street 1:12662 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1058
Practice Address - Country:US
Practice Address - Phone:503-546-7677
Practice Address - Fax:503-517-7768
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60778717101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)