Basic Information
| Provider Information | |||||||||
| NPI: | 1861760498 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE JESUS | ||||||||
| FirstName: | OMAR | ||||||||
| MiddleName: | E | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4751 WALDEN CIR APT C | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328117327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073090549 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2479 ALOMA AVE UNIT D | ||||||||
| Address2: | |||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327922541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076576692 | ||||||||
| FaxNumber: | 4078946010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2011 | ||||||||
| LastUpdateDate: | 12/10/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | D222-645-85-017-0 | FL | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.