Healthcare Provider Details

I. General information

NPI: 1528521606
Provider Name (Legal Business Name): MR. JESUS RAFAEL HERRERA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2019
Last Update Date: 06/17/2024
Certification Date:
Deactivation Date: 05/26/2024
Reactivation Date: 06/14/2024

III. Provider practice location address

219 WEST CHICAGO AVENUE SUITE 200
CHICAGO IL
60654
US

IV. Provider business mailing address

219 WEST CHICAGO AVENUE SUITE 200
CHICAGO IL
60654
US

V. Phone/Fax

Practice location:
  • Phone: 832-761-3176
  • Fax:
Mailing address:
  • Phone: 832-761-3176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: