Provider Demographics
NPI:1174272124
Name:FERNANDEZ, JANNY
Entity Type:Individual
Prefix:
First Name:JANNY
Middle Name:
Last Name:FERNANDEZ
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 1:2300 W 84TH ST STE 404A
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5773
Mailing Address - Country:US
Mailing Address - Phone:305-992-0160
Mailing Address - Fax:786-741-8837
Practice Address - Street 1:2300 W 84TH ST STE 404A
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-5773
Practice Address - Country:US
Practice Address - Phone:305-992-0160
Practice Address - Fax:786-741-8837
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106S00000XMedicaid