Provider Demographics
NPI:1649025446
Name:BLANCO HERNANDEZ, JESICA
Entity type:Individual
Prefix:
First Name:JESICA
Middle Name:
Last Name:BLANCO HERNANDEZ
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 1:10301 SW 212TH ST
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33189-3001
Mailing Address - Country:US
Mailing Address - Phone:754-268-0945
Mailing Address - Fax:
Practice Address - Street 1:13500 SW 88TH ST UNIT 285
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-1515
Practice Address - Country:US
Practice Address - Phone:786-706-2366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-340313106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty