Provider Demographics
NPI:1851808679
Name:DAZA, JENNIFER CAROLINA
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CAROLINA
Last Name:DAZA
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 1:1840 NW 125TH TER
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-2551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14359 MIRAMAR PARKWAY
Practice Address - Street 2:SUITE 504
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025
Practice Address - Country:US
Practice Address - Phone:954-399-2637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician