Provider Demographics
NPI:1134739204
Name:MEDINA, JANELYNN
Entity type:Individual
Prefix:MRS
First Name:JANELYNN
Middle Name:
Last Name:MEDINA
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 1:20326 NW 52ND PL LOT 752
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-4718
Mailing Address - Country:US
Mailing Address - Phone:786-606-7559
Mailing Address - Fax:
Practice Address - Street 1:20326 NW 52ND PL LOT 752
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-4718
Practice Address - Country:US
Practice Address - Phone:786-606-7559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-130252106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician