Healthcare Provider Details

I. General information

NPI: 1104770445
Provider Name (Legal Business Name): LUIS DE JESUS LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2026
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3639 W LINCOLN ST
PHOENIX AZ
85009-5516
US

IV. Provider business mailing address

3639 W LINCOLN ST
PHOENIX AZ
85009-5516
US

V. Phone/Fax

Practice location:
  • Phone: 602-233-9747
  • Fax:
Mailing address:
  • Phone: 602-233-9747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMSW-19044
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: