Healthcare Provider Details

I. General information

NPI: 1053167767
Provider Name (Legal Business Name): ELIZABETH DE JESUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 09/07/2025
Certification Date: 09/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31625 US-101
SOLEDAD CA
93960
US

IV. Provider business mailing address

PO BOX 920
GREENFIELD CA
93927-0920
US

V. Phone/Fax

Practice location:
  • Phone: 831-678-5500
  • Fax:
Mailing address:
  • Phone: --
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW131985
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: