Provider Demographics
NPI:1639694102
Name:JEFFERY, TAYLOR (RBT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:JEFFERY
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 1:2553 GALLIANO CIR
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-1513
Mailing Address - Country:US
Mailing Address - Phone:772-418-6972
Mailing Address - Fax:
Practice Address - Street 1:644 FERGUSON DR STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32805-1023
Practice Address - Country:US
Practice Address - Phone:407-574-4629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102165200Medicaid