Healthcare Provider Details

I. General information

NPI: 1720663016
Provider Name (Legal Business Name): JCIA FAMILY THERAPY CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2021
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 W 49TH PLACE SUITE 412
HIALEAH FL
33012-8142
US

IV. Provider business mailing address

1490 W 49TH PLACE SUITE 412
HIALEAH FL
33012-8142
US

V. Phone/Fax

Practice location:
  • Phone: 786-542-9896
  • Fax: 786-685-2167
Mailing address:
  • Phone: 786-542-9896
  • Fax: 786-685-2167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CARLOS A ROCA ULLOA
Title or Position: PRESIDENT
Credential:
Phone: 786-542-9896