Healthcare Provider Details

I. General information

NPI: 1558956136
Provider Name (Legal Business Name): MISS JAILENE CRESPO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2021
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2898 NW 79TH AVE
DORAL FL
33122-1033
US

IV. Provider business mailing address

2898 NW 79TH AVE
DORAL FL
33122-1033
US

V. Phone/Fax

Practice location:
  • Phone: 305-363-2969
  • Fax:
Mailing address:
  • Phone: 954-557-7790
  • Fax: 954-557-7780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-85950
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: