Healthcare Provider Details

I. General information

NPI: 1407424864
Provider Name (Legal Business Name): JEFFERESON QUISHPE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6953 UNIVERSITY BLVD
WINTER PARK FL
32792-6710
US

IV. Provider business mailing address

12150 RENAISSANCE CT UNIT 204
ORLANDO FL
32826-3984
US

V. Phone/Fax

Practice location:
  • Phone: 407-543-8356
  • Fax:
Mailing address:
  • Phone:
  • 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: