Provider Demographics
NPI:1255424941
Name:DEJESUS, DIANA WILLOW (OTR/L)
Entity type:Individual
Prefix:MS
First Name:DIANA
Middle Name:WILLOW
Last Name:DEJESUS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-4384
Mailing Address - Country:US
Mailing Address - Phone:530-879-9030
Mailing Address - Fax:530-879-9030
Practice Address - Street 1:2627 FOREST AVE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-4384
Practice Address - Country:US
Practice Address - Phone:530-879-9030
Practice Address - Fax:530-879-9030
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT267174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist