MEDICARE: JESSE JORDAN DAVIS RBT

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	BACB1084146	FL

General Provider Information

NPI Number	:	1689424400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE JORDAN DAVIS RBT

Provider Business Mailing Address
First Line	:	2522 LINCOLN ST APT 232
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33020-4108
Country	:	US
Telephone Number	:	770-895-7364
Fax Number	:

Provider Business Practice Location Address
First Line	:	2011 NE 60TH ST
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-2127
Country	:	US
Telephone Number	:	954-830-9508
Fax Number	:

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

Provider Enumeration Date	:	03/25/2024
Last Update Date	:	03/25/2024

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