Healthcare Provider Details

I. General information

NPI: 1245672179
Provider Name (Legal Business Name): TIFFANY ANN DE JESUS POWELL MS, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIFFANY A DE JESUS

II. Dates (important events)

Enumeration Date: 07/19/2013
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W WILLIAMS ST UNIT 346
APEX NC
27502-1998
US

IV. Provider business mailing address

6831 FOX LANDING WAY APT 642
RALEIGH NC
27616-7631
US

V. Phone/Fax

Practice location:
  • Phone: 908-930-2725
  • Fax:
Mailing address:
  • Phone: 908-930-2725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number15111
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: