Provider Demographics
NPI:1598090201
Name:PEREZ, JESUS (PSY D)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:PEREZ
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6429 COW PEN RD
Mailing Address - Street 2:#V104
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-7607
Mailing Address - Country:US
Mailing Address - Phone:757-329-4690
Mailing Address - Fax:
Practice Address - Street 1:4175 W 20TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-5874
Practice Address - Country:US
Practice Address - Phone:305-825-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-14
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7966103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical