Provider Demographics
NPI:1245960129
Name:ROQUE CARBALLO, JANNIS
Entity type:Individual
Prefix:
First Name:JANNIS
Middle Name:
Last Name:ROQUE CARBALLO
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 1:141 NE 24TH TER
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-6213
Mailing Address - Country:US
Mailing Address - Phone:786-712-1012
Mailing Address - Fax:
Practice Address - Street 1:141 NE 24TH TER
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-6213
Practice Address - Country:US
Practice Address - Phone:786-712-1012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113050400Medicaid