Provider Demographics
NPI:1639704083
Name:ESPINOSA, JEISON
Entity Type:Individual
Prefix:
First Name:JEISON
Middle Name:
Last Name:ESPINOSA
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 1:905 SW 9TH TER
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33315-1128
Mailing Address - Country:US
Mailing Address - Phone:954-513-8404
Mailing Address - Fax:
Practice Address - Street 1:905 SW 9TH TER
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33315-1128
Practice Address - Country:US
Practice Address - Phone:954-513-8404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-05
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-10-6987106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician