Provider Demographics
NPI:1023872199
Name:HERNANDEZ, JESUS MIGUEL
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:MIGUEL
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26100SW 144TH AVENUE RD
Mailing Address - Street 2:APT 114
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032
Mailing Address - Country:US
Mailing Address - Phone:786-216-4894
Mailing Address - Fax:
Practice Address - Street 1:26100SW 144TH AVENUE RD
Practice Address - Street 2:APT 114
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032
Practice Address - Country:US
Practice Address - Phone:786-216-4894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-09
Last Update Date:2024-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24320271106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician