Provider Demographics
NPI:1245926534
Name:ACOSTA, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ACOSTA
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 1:55 NE 26TH CT
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33334-1026
Mailing Address - Country:US
Mailing Address - Phone:786-731-1064
Mailing Address - Fax:
Practice Address - Street 1:12500 W ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-4085
Practice Address - Country:US
Practice Address - Phone:754-812-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-238058106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician