Provider Demographics
NPI:1164145447
Name:SMALLS, JENISE M (RBT)
Entity Type:Individual
Prefix:
First Name:JENISE
Middle Name:M
Last Name:SMALLS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6016 MAUSSER DR APT 2A
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-2929
Mailing Address - Country:US
Mailing Address - Phone:340-514-5382
Mailing Address - Fax:
Practice Address - Street 1:1514 E KALEY ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-4145
Practice Address - Country:US
Practice Address - Phone:808-271-1101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician