Provider Demographics
NPI:1447608120
Name:COLLANTES, JESSICA (BCABA)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:COLLANTES
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:COLLANTES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BCABA
Mailing Address - Street 1:3761 E 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-2838
Mailing Address - Country:US
Mailing Address - Phone:786-499-2716
Mailing Address - Fax:
Practice Address - Street 1:3761 E 8TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-2838
Practice Address - Country:US
Practice Address - Phone:786-499-2716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-17-7778106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104813300Medicaid