Provider Demographics
NPI:1780454140
Name:SALAZAR, JESUS MIGUEL
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:MIGUEL
Last Name:SALAZAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8632 NW 112TH CT
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-5610
Mailing Address - Country:US
Mailing Address - Phone:786-567-1598
Mailing Address - Fax:
Practice Address - Street 1:8632 NW 112TH CT
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-5610
Practice Address - Country:US
Practice Address - Phone:786-567-1598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-316629106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician