Healthcare Provider Details

I. General information

NPI: 1104746395
Provider Name (Legal Business Name): JAYDEN 8636400163 WELLS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2969 W MIDWAY RD
FORT PIERCE FL
34981-4956
US

IV. Provider business mailing address

1761 SW TIVAN LN
PORT SAINT LUCIE FL
34984-3613
US

V. Phone/Fax

Practice location:
  • Phone: 561-536-5888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT262829814
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: