Provider Demographics
NPI:1104486265
Name:MIRANDA, JESSICA A (RBT)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:A
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15230 SW 139TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-5022
Mailing Address - Country:US
Mailing Address - Phone:786-626-3522
Mailing Address - Fax:
Practice Address - Street 1:15230 SW 139TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-5022
Practice Address - Country:US
Practice Address - Phone:786-626-3522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19-86324106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician