Provider Demographics
NPI:1689980567
Name:MEDINA-SMESTER, MARCELLE
Entity Type:Individual
Prefix:
First Name:MARCELLE
Middle Name:
Last Name:MEDINA-SMESTER
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 1:3503 KERNAN BLVD S STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-3605
Mailing Address - Country:US
Mailing Address - Phone:904-417-8395
Mailing Address - Fax:844-231-8895
Practice Address - Street 1:3503 KERNAN BLVD S STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-3605
Practice Address - Country:US
Practice Address - Phone:904-417-8395
Practice Address - Fax:844-231-8895
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-30
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1689980567OtherINDIVIDUAL
FL1881060309OtherORGANIZATIONAL