Provider Demographics
NPI:1285208041
Name:ROSS EDWARDS, JAISA ANELEN
Entity Type:Individual
Prefix:
First Name:JAISA
Middle Name:ANELEN
Last Name:ROSS EDWARDS
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 1:5233 W 26TH AVE APT 33
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-4732
Mailing Address - Country:US
Mailing Address - Phone:786-878-4620
Mailing Address - Fax:
Practice Address - Street 1:5233 W 26TH AVE APT 33
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-4732
Practice Address - Country:US
Practice Address - Phone:786-878-4620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician