Provider Demographics
NPI:1942772470
Name:MENDOZA BERMUDEZ, JESSABEL
Entity Type:Individual
Prefix:
First Name:JESSABEL
Middle Name:
Last Name:MENDOZA BERMUDEZ
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 1:9747 NW 44TH TER
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-3368
Mailing Address - Country:US
Mailing Address - Phone:305-588-1623
Mailing Address - Fax:
Practice Address - Street 1:9747 NW 44TH TER
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-3368
Practice Address - Country:US
Practice Address - Phone:305-588-1623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-21
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-73358106S00000X
FL1-21-49996103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician