Provider Demographics
NPI:1003418849
Name:FAYETTE, JOUBERT
Entity Type:Individual
Prefix:
First Name:JOUBERT
Middle Name:
Last Name:FAYETTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14870 PLEASANT BAY LN APT 1103
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-7711
Mailing Address - Country:US
Mailing Address - Phone:239-601-7859
Mailing Address - Fax:
Practice Address - Street 1:8803 TAMIAMI TRL E
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34113-3347
Practice Address - Country:US
Practice Address - Phone:239-351-7075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBRT-20-143507106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician