Provider Demographics
NPI:1174293807
Name:BENAVIDES, JESSICA ISOLINA
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:ISOLINA
Last Name:BENAVIDES
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 1:9406 SUNSET CT APT 327
Mailing Address - Street 2:
Mailing Address - City:MANASSAS PARK
Mailing Address - State:VA
Mailing Address - Zip Code:20111-8296
Mailing Address - Country:US
Mailing Address - Phone:703-881-6032
Mailing Address - Fax:
Practice Address - Street 1:9406 SUNSET CT APT 327
Practice Address - Street 2:
Practice Address - City:MANASSAS PARK
Practice Address - State:VA
Practice Address - Zip Code:20111-8296
Practice Address - Country:US
Practice Address - Phone:703-881-6032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT21184197106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician