Healthcare Provider Details

I. General information

NPI: 1285543330
Provider Name (Legal Business Name): ANDREA ISABEL DE JESUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4917 GOLDEN TRIANGLE BLVD STE 421
FORT WORTH TX
76244-4673
US

IV. Provider business mailing address

8740 MAPLE RIDGE TRL
FORT WORTH TX
76244-1248
US

V. Phone/Fax

Practice location:
  • Phone: 817-754-4938
  • Fax: 817-717-8584
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-406498
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: