=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457168635
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JADE PERRY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2024
-----------------------------------------------------
Last Update Date | 12/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 212 STATE ROAD 436
-----------------------------------------------------
City | CASSELBERRY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32707-4943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 689-255-1075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3211 ARDEN VILLAS BLVD APT 17
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32817-2163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-697-5195
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------