Basic Information
| Provider Information | |||||||||
| NPI: | 1568821775 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | NICHOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOREJON | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | NICHOLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11755 SW 90TH ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331862178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058469807 | ||||||||
| FaxNumber: | 3058469711 | ||||||||
| Practice Location | |||||||||
| Address1: | 11755 SW 90TH ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331862178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058469807 | ||||||||
| FaxNumber: | 3058469711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2016 | ||||||||
| LastUpdateDate: | 02/16/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.