Provider Demographics
NPI:1558993295
Name:FORMAN, JAIRA ESTHEL TESORO (MA,BCBA)
Entity Type:Individual
Prefix:
First Name:JAIRA ESTHEL
Middle Name:TESORO
Last Name:FORMAN
Suffix:
Gender:F
Credentials:MA,BCBA
Other - Prefix:
Other - First Name:JAIRA ESTHEL
Other - Middle Name:TESORO
Other - Last Name:UALAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA,BCBA
Mailing Address - Street 1:6804 ARCHING BRANCH CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-8450
Mailing Address - Country:US
Mailing Address - Phone:904-401-3259
Mailing Address - Fax:
Practice Address - Street 1:6820 SOUTHPOINT PKWY STE 9
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6277
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL1-21-54032103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician