Provider Demographics
NPI:1649026543
Name:HERRERA, JAIME MAURICIO (OBHCMS)
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:MAURICIO
Last Name:HERRERA
Suffix:
Gender:M
Credentials:OBHCMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22790 SW 112TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33170-7602
Mailing Address - Country:US
Mailing Address - Phone:305-235-2616
Mailing Address - Fax:
Practice Address - Street 1:22790 SW 112TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33170-7602
Practice Address - Country:US
Practice Address - Phone:305-235-2616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCMS.0102663171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator