Provider Demographics
NPI:1164098042
Name:DE JESUS BAEZ, JESSIE IVETTE
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:IVETTE
Last Name:DE JESUS BAEZ
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 1:680 WOODLAND CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-1110
Mailing Address - Country:US
Mailing Address - Phone:413-459-7043
Mailing Address - Fax:
Practice Address - Street 1:3201 BUDINGER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-7203
Practice Address - Country:US
Practice Address - Phone:413-459-7043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician