Provider Demographics
NPI:1033800453
Name:VALDES, JESENIA (OWNER)
Entity Type:Individual
Prefix:
First Name:JESENIA
Middle Name:
Last Name:VALDES
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21316 NW 40TH CIRCLE CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-1180
Mailing Address - Country:US
Mailing Address - Phone:305-766-4064
Mailing Address - Fax:
Practice Address - Street 1:2300 W 84TH ST STE 601
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-5780
Practice Address - Country:US
Practice Address - Phone:305-766-4064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TP0016X, 103TM1800X
FL103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty