Healthcare Provider Details

I. General information

NPI: 1699696922
Provider Name (Legal Business Name): JAIDEN M BIRDSALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 SE HILLMOOR DR STE B101-103
PORT SAINT LUCIE FL
34952-7553
US

IV. Provider business mailing address

406 HOMESTEAD AVE NE
PALM BAY FL
32907-2341
US

V. Phone/Fax

Practice location:
  • Phone: 772-463-0444
  • Fax:
Mailing address:
  • Phone: 321-271-7745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: