Provider Demographics
NPI:1548328305
Name:DANTILUS, JEAN RUBENS
Entity type:Individual
Prefix:MR
First Name:JEAN
Middle Name:RUBENS
Last Name:DANTILUS
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 1:555 NW TWYLITE TER
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-1144
Mailing Address - Country:US
Mailing Address - Phone:772-871-9270
Mailing Address - Fax:772-460-8050
Practice Address - Street 1:555 NW TWYLITE TER
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-1144
Practice Address - Country:US
Practice Address - Phone:772-979-0288
Practice Address - Fax:772-871-9270
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
FL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker