Provider Demographics
NPI:1962745497
Name:DEJESUS, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DEJESUS
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 1:305 NE LOOP 820
Mailing Address - Street 2:BUSINESS TOWER 1; SUITE 200
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-7209
Mailing Address - Country:US
Mailing Address - Phone:817-292-8787
Mailing Address - Fax:817-789-6849
Practice Address - Street 1:921 SHILOH RD
Practice Address - Street 2:SUITE C-120
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1431
Practice Address - Country:US
Practice Address - Phone:903-838-7604
Practice Address - Fax:817-789-6849
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-03
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111213225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207164901Medicaid
TX149984001Medicaid
TX149984001Medicaid
TX207164901Medicaid