Healthcare Provider Details

I. General information

NPI: 1457962979
Provider Name (Legal Business Name): JESSIE BURGOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2020
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3175 S CONGRESS AVE STE 103
PALM SPRINGS FL
33461-2502
US

IV. Provider business mailing address

1997 SE AIROSO BLVD
PORT SAINT LUCIE FL
34984-4528
US

V. Phone/Fax

Practice location:
  • Phone: 561-729-6631
  • Fax: 561-771-6630
Mailing address:
  • Phone: 772-722-4496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number19-104745
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: