Healthcare Provider Details

I. General information

NPI: 1003779984
Provider Name (Legal Business Name): MR. JOHN JOSPEH DEJESUS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 GROVE AVE
NORWALK OH
44857-1804
US

IV. Provider business mailing address

4 GROVE AVE
NORWALK OH
44857-1804
US

V. Phone/Fax

Practice location:
  • Phone: 419-202-5278
  • Fax:
Mailing address:
  • Phone: 419-202-5278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberKST3591
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: