Provider Demographics
NPI:1619605698
Name:BENEVIDES, JESSICA SUZANNE (RBT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUZANNE
Last Name:BENEVIDES
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 RUSTIC RIDGE LOOP APT 102A
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-7713
Mailing Address - Country:US
Mailing Address - Phone:508-317-8416
Mailing Address - Fax:
Practice Address - Street 1:10817 BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-3616
Practice Address - Country:US
Practice Address - Phone:866-311-4617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-22-224761106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician