Healthcare Provider Details

I. General information

NPI: 1336823251
Provider Name (Legal Business Name): JESSICA REQUEJADO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9970 CENTRAL PARK BLVD N STE 401
BOCA RATON FL
33428-2252
US

IV. Provider business mailing address

11951 SW 123RD AVE
MIAMI FL
33186-5066
US

V. Phone/Fax

Practice location:
  • Phone: 305-807-1909
  • Fax:
Mailing address:
  • Phone: 786-281-5259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: