Provider Demographics
NPI:1528521606
Name:HERRERA, JESUS RAFAEL
Entity type:Individual
Prefix:MR
First Name:JESUS
Middle Name:RAFAEL
Last Name:HERRERA
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 1:219 WEST CHICAGO AVENUE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654
Mailing Address - Country:US
Mailing Address - Phone:832-761-3176
Mailing Address - Fax:
Practice Address - Street 1:219 WEST CHICAGO AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654
Practice Address - Country:US
Practice Address - Phone:832-761-3176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-07
Last Update Date:2024-06-17
Deactivation Date:2024-05-26
Deactivation Code:
Reactivation Date:2024-06-14
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician