Provider Demographics
NPI:1346854312
Name:FERNANDEZ, JONATHAN E
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:E
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12975 SW 192ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-3735
Mailing Address - Country:US
Mailing Address - Phone:305-281-8762
Mailing Address - Fax:
Practice Address - Street 1:12975 SW 192ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-3735
Practice Address - Country:US
Practice Address - Phone:305-281-8762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-07
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20127265106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician