Provider Demographics
NPI:1407399157
Name:QUICENO, JESUS
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:QUICENO
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 1:2233 N COMMERCE PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-3252
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2233 N COMMERCE PKWY STE 1
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-3252
Practice Address - Country:US
Practice Address - Phone:954-356-2878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA13974224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant