=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225524176
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA L STEGEMAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2018
-----------------------------------------------------
Last Update Date | 11/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12421 SAN JOSE BLVD STE 300
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32223-8659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-521-0242
-----------------------------------------------------
Fax | 904-683-3670
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12421 SAN JOSE BLVD STE 300
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32223-8659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-521-0242
-----------------------------------------------------
Fax | 904-683-3670
-----------------------------------------------------
=====================================================
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-18-54766
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------