=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194588590
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER ANTUANETTE ACOSTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2024
-----------------------------------------------------
Last Update Date | 01/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 419 S PARK AVE
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32771-1933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-780-9386
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11014 ISLAND BAY CIR
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32771-6351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-814-8202
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-24-323566
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------