MEDICARE: JUSTINE FUENTES

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

General Provider Information

NPI Number	:	1952819914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTINE FUENTES

Provider Business Mailing Address
First Line	:	2840 HENDERSON DR
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-5242
Country	:	US
Telephone Number	:	910-378-2501
Fax Number	:

Provider Business Practice Location Address
First Line	:	2840 HENDERSON DR
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-5242
Country	:	US
Telephone Number	:	910-378-2501
Fax Number	:

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

Provider Enumeration Date	:	01/11/2018
Last Update Date	:	01/11/2018

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Directions to “ JUSTINE FUENTES ” Practice Location

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