Provider Demographics
NPI:1609366616
Name:EWALD, JESS
Entity Type:Individual
Prefix:
First Name:JESS
Middle Name:
Last Name:EWALD
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 1:6160 CAMP LEE RD
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33417-5517
Mailing Address - Country:US
Mailing Address - Phone:561-767-2726
Mailing Address - Fax:
Practice Address - Street 1:6160 CAMP LEE RD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33417-5517
Practice Address - Country:US
Practice Address - Phone:561-767-2726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician