Healthcare Provider Details

I. General information

NPI: 1467282616
Provider Name (Legal Business Name): JENNISPHER ROQUE DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2024
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 SW 149TH AVE APT A212
MIAMI FL
33193-1408
US

IV. Provider business mailing address

8000 SW 149TH AVE APT A212
MIAMI FL
33193-1408
US

V. Phone/Fax

Practice location:
  • Phone: 786-754-8051
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-348754
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: