Provider Demographics
NPI:1760803969
Name:PIBERNUS, JESSICA E (MA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:E
Last Name:PIBERNUS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5588 W 17TH CT
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-2068
Mailing Address - Country:US
Mailing Address - Phone:787-598-6883
Mailing Address - Fax:
Practice Address - Street 1:3625 NW 82ND AVE
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6652
Practice Address - Country:US
Practice Address - Phone:787-598-6883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-16
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4321103TC1900X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling