Provider Demographics
NPI:1316038078
Name:LUIS, JESELYN (MSED)
Entity Type:Individual
Prefix:
First Name:JESELYN
Middle Name:
Last Name:LUIS
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11031 NE 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-7182
Mailing Address - Country:US
Mailing Address - Phone:305-398-6100
Mailing Address - Fax:305-757-4465
Practice Address - Street 1:140 NW 59TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33127-1218
Practice Address - Country:US
Practice Address - Phone:305-759-8888
Practice Address - Fax:305-757-5989
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9618101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health