Healthcare Provider Details

I. General information

NPI: 1164256475
Provider Name (Legal Business Name): JESUS ANGEL CANEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8354 E NORTHFIELD BLVD UNIT 3700
DENVER CO
80238-3135
US

IV. Provider business mailing address

4514 W ROSE LN
GLENDALE AZ
85301-4833
US

V. Phone/Fax

Practice location:
  • Phone: 720-961-3764
  • Fax:
Mailing address:
  • Phone: 602-907-8781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number22-233513
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: