Provider Demographics
NPI:1063830552
Name:JAS, JACKELINE
Entity Type:Individual
Prefix:
First Name:JACKELINE
Middle Name:
Last Name:JAS
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 1:13195 SW 134TH ST STE 106
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4585
Mailing Address - Country:US
Mailing Address - Phone:786-250-3220
Mailing Address - Fax:786-431-2551
Practice Address - Street 1:11060 SW 88TH ST
Practice Address - Street 2:B100
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-1272
Practice Address - Country:US
Practice Address - Phone:305-668-8644
Practice Address - Fax:305-668-6010
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11621481103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst