Provider Demographics
NPI:1588113732
Name:DE JESUS, REY WILFREDO (SW)
Entity type:Individual
Prefix:MR
First Name:REY
Middle Name:WILFREDO
Last Name:DE JESUS
Suffix:
Gender:M
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 CALLE BUZARDO
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00924-3302
Mailing Address - Country:US
Mailing Address - Phone:787-399-9041
Mailing Address - Fax:
Practice Address - Street 1:890 CALLE BUZARDO
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924-3302
Practice Address - Country:US
Practice Address - Phone:787-399-9041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11623104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker