Provider Demographics
NPI:1457077877
Name:JEAN, LWIDGINA S
Entity Type:Individual
Prefix:
First Name:LWIDGINA
Middle Name:S
Last Name:JEAN
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 1:9000 BURMA RD STE 109
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33403-1606
Mailing Address - Country:US
Mailing Address - Phone:561-508-6122
Mailing Address - Fax:
Practice Address - Street 1:1710 4TH AVE N
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-2874
Practice Address - Country:US
Practice Address - Phone:561-719-1739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician