Provider Demographics
NPI:1972230753
Name:DEJESUS, KELLY (LCSWA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DEJESUS
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 SMOKE PL
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-5989
Mailing Address - Country:US
Mailing Address - Phone:919-868-0492
Mailing Address - Fax:
Practice Address - Street 1:3937 WESTERN BLVD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-1936
Practice Address - Country:US
Practice Address - Phone:919-821-0790
Practice Address - Fax:919-518-9476
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0179891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical