Provider Demographics
NPI:1851037345
Name:DE JESUS, KAREN NICOLE
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:NICOLE
Last Name:DE JESUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 SPRING ST STE 203
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-0273
Mailing Address - Country:US
Mailing Address - Phone:619-549-0329
Mailing Address - Fax:
Practice Address - Street 1:4700 SPRING ST STE 203
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-0273
Practice Address - Country:US
Practice Address - Phone:619-549-0329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-09
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA143061106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program