Provider Demographics
NPI:1790389070
Name:MESA, JORGE O
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:O
Last Name:MESA
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 1:14736 SW 87TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-1538
Mailing Address - Country:US
Mailing Address - Phone:786-488-0469
Mailing Address - Fax:
Practice Address - Street 1:14736 SW 87TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-1538
Practice Address - Country:US
Practice Address - Phone:786-488-0469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-26
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician