Provider Demographics
NPI:1346897774
Name:WATERS- HERALD, DEJUANA
Entity type:Individual
Prefix:
First Name:DEJUANA
Middle Name:
Last Name:WATERS- HERALD
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 1:1056 CADILLAC BLVD
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44320-2904
Mailing Address - Country:US
Mailing Address - Phone:614-779-9739
Mailing Address - Fax:
Practice Address - Street 1:1056 CADILLAC BLVD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-2904
Practice Address - Country:US
Practice Address - Phone:330-803-9121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH172V00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker