Provider Demographics
NPI:1174258990
Name:CARVAJAL, JESSICA (LAC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CARVAJAL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 SANS SOUCI BLVD APT 206
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33181-3032
Mailing Address - Country:US
Mailing Address - Phone:305-877-9947
Mailing Address - Fax:
Practice Address - Street 1:975 ARTHUR GODFREY RD STE 211
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-3341
Practice Address - Country:US
Practice Address - Phone:305-877-9947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP4355171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist