Provider Demographics
NPI:1740034073
Name:SIMON, MIRSADA JACLYN
Entity type:Individual
Prefix:
First Name:MIRSADA
Middle Name:JACLYN
Last Name:SIMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRSADA
Other - Middle Name:JACLYN
Other - Last Name:OLIVERAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:445 MONUMENT RD APT 521
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-6452
Mailing Address - Country:US
Mailing Address - Phone:347-216-2343
Mailing Address - Fax:
Practice Address - Street 1:13121 ATLANTIC BLVD STE 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-0102
Practice Address - Country:US
Practice Address - Phone:904-491-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEBACB749816106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician