Provider Demographics
NPI:1609451715
Name:ULYSSE, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:ULYSSE
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 1:1040 NE 162ND ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-3823
Mailing Address - Country:US
Mailing Address - Phone:305-465-1228
Mailing Address - Fax:
Practice Address - Street 1:4699 N STATE ROAD 7 STE B1
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33319-5870
Practice Address - Country:US
Practice Address - Phone:305-465-1228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT3428106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist