Provider Demographics
NPI:1730842378
Name:DE JESUS, ELITZIA J (LCDA)
Entity type:Individual
Prefix:
First Name:ELITZIA
Middle Name:J
Last Name:DE JESUS
Suffix:
Gender:F
Credentials:LCDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 67 BOX 18195
Mailing Address - Street 2:
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738-9432
Mailing Address - Country:US
Mailing Address - Phone:214-791-3635
Mailing Address - Fax:
Practice Address - Street 1:URB. INDUSTRIAL LAS FLORES CARR. 3 KM 23.9
Practice Address - Street 2:
Practice Address - City:RIO GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00721
Practice Address - Country:US
Practice Address - Phone:787-704-0705
Practice Address - Fax:787-751-3755
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3092103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist