Healthcare Provider Details

I. General information

NPI: 1063305258
Provider Name (Legal Business Name): JESSICA MARIEN ROQUE SR.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2025
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2745 SW 6TH ST APT 4
MIAMI FL
33135-2871
US

IV. Provider business mailing address

2745 SW 6TH ST APT 4 APARTAMENTO 4
MIAMI FL
33135-2871
US

V. Phone/Fax

Practice location:
  • Phone: 786-793-7883
  • Fax: 786-793-7883
Mailing address:
  • Phone: 786-793-7883
  • Fax: 786-793-7883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-438511
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: