Provider Demographics
NPI:1073380226
Name:BAZAN MORENO, JESENIA
Entity Type:Individual
Prefix:
First Name:JESENIA
Middle Name:
Last Name:BAZAN MORENO
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 1:3325 S KIRKMAN RD APT 437
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-2493
Mailing Address - Country:US
Mailing Address - Phone:830-446-2195
Mailing Address - Fax:
Practice Address - Street 1:319 W OAK ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4421
Practice Address - Country:US
Practice Address - Phone:407-895-0801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician