Healthcare Provider Details

I. General information

NPI: 1760197644
Provider Name (Legal Business Name): JESSICA LANE RE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2023
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11901 JESSICA LN
RAYTOWN MO
64138-2639
US

IV. Provider business mailing address

100 SE 3RD AVE STE 1800
FT LAUDERDALE FL
33394-0011
US

V. Phone/Fax

Practice location:
  • Phone: 754-300-3120
  • Fax: 888-919-4431
Mailing address:
  • Phone: 305-785-5520
  • Fax: 888-919-4431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: BELINA SURUJON
Title or Position: CONTRACTING & LICENSING DIRECTOR
Credential:
Phone: 305-785-5520