Provider Demographics
NPI:1588234819
Name:SANJUR, JESSICA
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:SANJUR
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5614 PINNACLE HEIGHTS CIR APT 303
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-4017
Mailing Address - Country:US
Mailing Address - Phone:813-504-6195
Mailing Address - Fax:
Practice Address - Street 1:5614 PINNACLE HEIGHTS CIR APT 303
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-4017
Practice Address - Country:US
Practice Address - Phone:813-504-6195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21-170195106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician