Provider Demographics
NPI:1629276233
Name:KHAMVONGSA, JESSICA FREMSON (EDS)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:FREMSON
Last Name:KHAMVONGSA
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10060 SW 57TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-2000
Mailing Address - Country:US
Mailing Address - Phone:305-710-2226
Mailing Address - Fax:305-662-5277
Practice Address - Street 1:1390 S DIXIE HIGHWAY
Practice Address - Street 2:SUITE 1305
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146
Practice Address - Country:US
Practice Address - Phone:305-662-2686
Practice Address - Fax:305-668-9503
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool