Provider Demographics
NPI:1871850172
Name:CHILDERS, JESSICA KAE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KAE
Last Name:CHILDERS
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 1:500 FAIRWAY DR STE 102
Mailing Address - Street 2:888-880-9270
Mailing Address - City:DEERFIELD BCH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-1817
Mailing Address - Country:US
Mailing Address - Phone:888-880-9270
Mailing Address - Fax:
Practice Address - Street 1:2708 NE 14TH ST APT 5
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-3564
Practice Address - Country:US
Practice Address - Phone:888-880-9270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCODE 222Q00000XOtherTAXONOMY: 22 RESPIRATORY, DEVELOPMENTAL SERVICE PROVIDERS