Provider Demographics
NPI:1407554728
Name:SUAREZ, JASON GUSTAVO
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:GUSTAVO
Last Name:SUAREZ
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 1:843 SW 104TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-2755
Mailing Address - Country:US
Mailing Address - Phone:786-538-2216
Mailing Address - Fax:
Practice Address - Street 1:843 SW 104TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-2755
Practice Address - Country:US
Practice Address - Phone:786-538-2216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician