Provider Demographics
NPI:1821896614
Name:MENDIETA, JESSICA JOLIE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:JOLIE
Last Name:MENDIETA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7971 RIVIERA BLVD STE 402
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33023-6449
Mailing Address - Country:US
Mailing Address - Phone:954-642-1186
Mailing Address - Fax:
Practice Address - Street 1:7971 RIVIERA BLVD STE 402
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33023-6449
Practice Address - Country:US
Practice Address - Phone:954-642-1186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-06
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1243416106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician