Provider Demographics
NPI:1689424400
Name:DAVIS, JESSE JORDAN (RBT)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:JORDAN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2522 LINCOLN ST APT 232
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-4108
Mailing Address - Country:US
Mailing Address - Phone:770-895-7364
Mailing Address - Fax:
Practice Address - Street 1:2011 NE 60TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-2127
Practice Address - Country:US
Practice Address - Phone:954-830-9508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1084146103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst