MEDICARE: JACQUELINE FERNANDEZ PADRON

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	106S00000X	Behavior Technician	RBT20-119352	FL

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	:	1750055422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE FERNANDEZ PADRON

Provider Business Mailing Address
First Line	:	4081 NW 65TH AVE APT 1
Second Line	:
City	:	VIRGINIA GARDENS
State	:	FL
Zip	:	33166-6939
Country	:	US
Telephone Number	:	502-650-1100
Fax Number	:

Provider Business Practice Location Address
First Line	:	4081 NW 65TH AVE APT 1
Second Line	:
City	:	VIRGINIA GARDENS
State	:	FL
Zip	:	33166-6939
Country	:	US
Telephone Number	:	502-650-1100
Fax Number	:

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

Provider Enumeration Date	:	08/05/2021
Last Update Date	:	08/05/2021

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