Healthcare Provider Details

I. General information

NPI: 1194588590
Provider Name (Legal Business Name): JENNIFER ANTUANETTE ACOSTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2024
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 MOSELEY AVE
PALATKA FL
32177-4937
US

IV. Provider business mailing address

11014 ISLAND BAY CIR
SANFORD FL
32771-6351
US

V. Phone/Fax

Practice location:
  • Phone: 812-814-8202
  • Fax:
Mailing address:
  • Phone: 812-814-8202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-323566
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: