Healthcare Provider Details

I. General information

NPI: 1235065103
Provider Name (Legal Business Name): JESSE FERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3718 SW 21ST PL
CAPE CORAL FL
33914-5425
US

IV. Provider business mailing address

3718 SW 21ST PL
CAPE CORAL FL
33914-5425
US

V. Phone/Fax

Practice location:
  • Phone: 239-747-8746
  • Fax:
Mailing address:
  • Phone: 239-747-8746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-543121
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: