Healthcare Provider Details

I. General information

NPI: 1568821775
Provider Name (Legal Business Name): JESSICA NICHOLE GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA NICHOLE MOREJON

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 EAST BROAD STREET #90
FUQUAY VARINA NC
27526-1968
US

IV. Provider business mailing address

1441 EAST BROAD STREET #90
FUQUAY VARINA NC
27526-1968
US

V. Phone/Fax

Practice location:
  • Phone: 305-322-3494
  • Fax: 772-675-9100
Mailing address:
  • Phone: 305-322-3494
  • Fax: 772-675-9100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: