Healthcare Provider Details

I. General information

NPI: 1326390329
Provider Name (Legal Business Name): JISSENIA PEREZ MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14008 SAULK CT APT 137
TAMPA FL
33613-3943
US

IV. Provider business mailing address

14008 SAULK CT APT 137
TAMPA FL
33613-3943
US

V. Phone/Fax

Practice location:
  • Phone: 813-420-2682
  • Fax:
Mailing address:
  • Phone: 813-420-2682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3796
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: