Provider Demographics
NPI:1336498443
Name:URENA, JESSICA CAROLINA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:CAROLINA
Last Name:URENA
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 1:259 E. OAKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:259 E. OAKDALE AVE
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539
Practice Address - Country:US
Practice Address - Phone:850-682-1234
Practice Address - Fax:850-689-8799
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13856101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health