MEDICARE: JENNIFER DAWN VERGARA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106E00000X	Assistant Behavior Analyst	0167393
2	103K00000X	Behavior Analyst

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053762401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER DAWN VERGARA

Provider Business Mailing Address
First Line	:	2527 EDGEWATER FALLS DR
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-2297
Country	:	US
Telephone Number	:	561-319-6697
Fax Number	:

Provider Business Practice Location Address
First Line	:	5628 36TH AVE N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33710-1914
Country	:	US
Telephone Number	:	727-424-1578
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2016
Last Update Date	:	08/08/2023

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