Provider Demographics
NPI:1851035265
Name:PETTY, JESSE WILLIAM (RBT)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:WILLIAM
Last Name:PETTY
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 1:495 ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-2555
Mailing Address - Country:US
Mailing Address - Phone:321-279-8972
Mailing Address - Fax:
Practice Address - Street 1:495 ORANGE AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-2555
Practice Address - Country:US
Practice Address - Phone:321-279-8972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB745497106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician