Provider Demographics
NPI:1568115574
Name:HERNANDEZ MARTINEZ, JORGE LUIS
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:HERNANDEZ MARTINEZ
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 1:521 PEERLESS CIR
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33974-9493
Mailing Address - Country:US
Mailing Address - Phone:239-703-3171
Mailing Address - Fax:
Practice Address - Street 1:2011 CHURCHILL AVE
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33971-5665
Practice Address - Country:US
Practice Address - Phone:239-703-3171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-31
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician