Provider Demographics
NPI:1720975956
Name:FUENTES GONZALEZ, JORDAN R
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:R
Last Name:FUENTES GONZALEZ
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 1:1919 TRAVIS RD
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-5262
Mailing Address - Country:US
Mailing Address - Phone:561-507-6667
Mailing Address - Fax:
Practice Address - Street 1:1919 TRAVIS RD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-5262
Practice Address - Country:US
Practice Address - Phone:561-507-6667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-20
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-25-430661106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician