Provider Demographics
NPI:1356851612
Name:SALAZAR, JESSENIA A
Entity Type:Individual
Prefix:
First Name:JESSENIA
Middle Name:A
Last Name:SALAZAR
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 1:5 REVERE DR STE 120
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-8005
Mailing Address - Country:US
Mailing Address - Phone:877-350-5005
Mailing Address - Fax:813-337-0937
Practice Address - Street 1:27716 CASHFORD CIR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-6962
Practice Address - Country:US
Practice Address - Phone:877-350-5005
Practice Address - Fax:813-337-0937
Is Sole Proprietor?:No
Enumeration Date:2017-10-01
Last Update Date:2020-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-18-53348106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician