Provider Demographics
NPI:1093463523
Name:AVILES, JIANAH ISABELLA (106S00000X)
Entity Type:Individual
Prefix:
First Name:JIANAH
Middle Name:ISABELLA
Last Name:AVILES
Suffix:
Gender:F
Credentials:106S00000X
Other - Prefix:MS
Other - First Name:JIANAH
Other - Middle Name:I
Other - Last Name:AVILES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:106S00000X
Mailing Address - Street 1:1540 NW 128TH DR
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-5212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1540 NW 128TH DR
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-5212
Practice Address - Country:US
Practice Address - Phone:305-467-4298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty