Provider Demographics
NPI:1629691977
Name:VALDES AVILES, JENNIFER MANUELA
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MANUELA
Last Name:VALDES AVILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27203 SW 157TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33031-3101
Mailing Address - Country:US
Mailing Address - Phone:786-370-7059
Mailing Address - Fax:
Practice Address - Street 1:27203 SW 157TH AVE
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33031-3101
Practice Address - Country:US
Practice Address - Phone:786-370-7059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-117468106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician