MEDICARE: JESSICA BALOS

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	101YM0800X	Mental Health Counselor	MH16234	FL

General Provider Information

NPI Number	:	1841743002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA BALOS

Provider Business Mailing Address
First Line	:	5775 AVISTA DR
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34243-3616
Country	:	US
Telephone Number	:	941-404-6304
Fax Number	:

Provider Business Practice Location Address
First Line	:	9015 TOWN CENTER PKWY UNIT 107
Second Line	:
City	:	LAKEWOOD RANCH
State	:	FL
Zip	:	34202-5012
Country	:	US
Telephone Number	:	941-404-6304
Fax Number	:

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

Provider Enumeration Date	:	07/24/2016
Last Update Date	:	01/18/2019

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