Healthcare Provider Details

I. General information

NPI: 1386184760
Provider Name (Legal Business Name): JESSICA EVANS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2017
Last Update Date: 03/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 GULF BEACH HWY
PENSACOLA FL
32507-2831
US

IV. Provider business mailing address

5220 PLEATEAU RD
PENSACOLA FL
32507-9057
US

V. Phone/Fax

Practice location:
  • Phone: 850-471-8668
  • Fax: 850-361-3443
Mailing address:
  • Phone: 812-890-3548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: