Healthcare Provider Details

I. General information

NPI: 1548190507
Provider Name (Legal Business Name): JESENIA ISIS CORREA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 WAVERLEY OAKS RD STE 101
WALTHAM MA
02452-8497
US

IV. Provider business mailing address

175Q CENTRE ST APT 1722
QUINCY MA
02169-8607
US

V. Phone/Fax

Practice location:
  • Phone: 781-894-6564
  • Fax:
Mailing address:
  • Phone: 512-590-5540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: