MEDICARE: JORDAN R FUENTES GONZALEZ

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	106S00000X	Behavior Technician	RBT-25-430661	FL

General Provider Information

NPI Number	:	1720975956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN R FUENTES GONZALEZ

Provider Business Mailing Address
First Line	:	1919 TRAVIS RD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33406-5262
Country	:	US
Telephone Number	:	561-507-6667
Fax Number	:

Provider Business Practice Location Address
First Line	:	1919 TRAVIS RD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33406-5262
Country	:	US
Telephone Number	:	561-507-6667
Fax Number	:

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

Provider Enumeration Date	:	06/20/2025
Last Update Date	:	07/31/2025

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