Provider Demographics
NPI:1043980105
Name:STREETER, JALISA
Entity Type:Individual
Prefix:
First Name:JALISA
Middle Name:
Last Name:STREETER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 8TH MNR APT 204
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-6840
Mailing Address - Country:US
Mailing Address - Phone:772-501-0238
Mailing Address - Fax:
Practice Address - Street 1:455 8TH MNR APT 204
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6840
Practice Address - Country:US
Practice Address - Phone:772-501-0238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion