Healthcare Provider Details

I. General information

NPI: 1962290965
Provider Name (Legal Business Name): REBEKAH MONIQUE DE JESUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2025
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 WELLS ST
LAS CRUCES NM
88003-1304
US

IV. Provider business mailing address

320 SAINT VINCENT DR
ST AUGUSTINE FL
32092-5407
US

V. Phone/Fax

Practice location:
  • Phone: 915-540-2350
  • Fax:
Mailing address:
  • Phone: 915-540-2350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: