Provider Demographics
NPI:1063956563
Name:JUSTO, JESSICA NICOLE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:JUSTO
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 1:5058 SW 170TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-4922
Mailing Address - Country:US
Mailing Address - Phone:954-805-2360
Mailing Address - Fax:
Practice Address - Street 1:12051 W OKEECHOBEE RD
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-2933
Practice Address - Country:US
Practice Address - Phone:954-805-2360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician