Provider Demographics
NPI:1770286874
Name:FUENTES, JAYME TAHILAH
Entity type:Individual
Prefix:
First Name:JAYME
Middle Name:TAHILAH
Last Name:FUENTES
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 1:9170 NW 19TH PL
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33322-3702
Mailing Address - Country:US
Mailing Address - Phone:954-600-1057
Mailing Address - Fax:
Practice Address - Street 1:9170 NW 19TH PL
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33322-3702
Practice Address - Country:US
Practice Address - Phone:954-600-1057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH21932101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health