Healthcare Provider Details

I. General information

NPI: 1194477281
Provider Name (Legal Business Name): JESSICA M ROQUE PACHECO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2022
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2343 NW 87TH ST
MIAMI FL
33147-3815
US

IV. Provider business mailing address

2343 NW 87TH ST
MIAMI FL
33147-3815
US

V. Phone/Fax

Practice location:
  • Phone: 786-450-8162
  • Fax:
Mailing address:
  • Phone: 786-450-8162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-198659
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: