Provider Demographics
NPI:1114433661
Name:TRAVIESO INCLAN, JAIME
Entity Type:Individual
Prefix:MR
First Name:JAIME
Middle Name:
Last Name:TRAVIESO INCLAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 45TH ST STE 202
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-2009
Mailing Address - Country:US
Mailing Address - Phone:561-823-8250
Mailing Address - Fax:
Practice Address - Street 1:2151 45TH ST STE 202
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-2009
Practice Address - Country:US
Practice Address - Phone:561-823-8250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-20
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician