Healthcare Provider Details

I. General information

NPI: 1679050413
Provider Name (Legal Business Name): JENNIFER REBECCA JANUSAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2018
Last Update Date: 07/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29228 US HIGHWAY 19 N
CLEARWATER FL
33761-2101
US

IV. Provider business mailing address

14099 BELCHER RD S LOT 1086
LARGO FL
33771-4519
US

V. Phone/Fax

Practice location:
  • Phone: 727-351-4191
  • Fax:
Mailing address:
  • Phone: 386-361-1768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-57585
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: