Provider Demographics
NPI:1942772868
Name:PAGAN, JARED R (RBT)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:R
Last Name:PAGAN
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 1:3018 BLAINE CIR
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-5327
Mailing Address - Country:US
Mailing Address - Phone:386-848-8114
Mailing Address - Fax:
Practice Address - Street 1:4647 CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-3000
Practice Address - Country:US
Practice Address - Phone:386-767-3752
Practice Address - Fax:386-767-4319
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-73677106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10775100Medicaid