Provider Demographics
NPI:1245879428
Name:HERNANDEZ IZQUIERDO, JESUS
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:HERNANDEZ IZQUIERDO
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 1:734 SW 101ST COURT CIR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-1879
Mailing Address - Country:US
Mailing Address - Phone:786-339-5689
Mailing Address - Fax:
Practice Address - Street 1:734 SW 101ST COURT CIR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-1879
Practice Address - Country:US
Practice Address - Phone:786-339-5689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-05
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-361726106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty