Healthcare Provider Details

I. General information

NPI: 1649695164
Provider Name (Legal Business Name): BENJAMIN JOSEPH DE JESUS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2014
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 S MCCLINTOCK DR STE 105
TEMPE AZ
85282-2692
US

IV. Provider business mailing address

1166 E WARNER RD STE 101T
GILBERT AZ
85296-3065
US

V. Phone/Fax

Practice location:
  • Phone: 480-804-0326
  • Fax:
Mailing address:
  • Phone: 480-375-1317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW 16081
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: