MEDICARE: JESSICA NICHOLE GOMEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1568821775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA NICHOLE GOMEZ

Provider Business Mailing Address
First Line	:	1441 EAST BROAD STREET
Second Line	:	#90
City	:	FUQUAY VARINA
State	:	NC
Zip	:	27526-1968
Country	:	US
Telephone Number	:	305-322-3494
Fax Number	:	772-675-9100

Provider Business Practice Location Address
First Line	:	1441 EAST BROAD STREET
Second Line	:	#90
City	:	FUQUAY VARINA
State	:	NC
Zip	:	27526-1968
Country	:	US
Telephone Number	:	305-322-3494
Fax Number	:	772-675-9100

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2016
Last Update Date	:	12/11/2025

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