Healthcare Provider Details

I. General information

NPI: 1063830552
Provider Name (Legal Business Name): JACKELINE JAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11060 SW 88TH ST B100
MIAMI FL
33176-1272
US

IV. Provider business mailing address

13195 SW 134TH ST STE 106
MIAMI FL
33186-4585
US

V. Phone/Fax

Practice location:
  • Phone: 305-668-8644
  • Fax: 305-668-6010
Mailing address:
  • Phone: 786-250-3220
  • Fax: 786-431-2551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number11621481
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: