Provider Demographics
NPI:1194588590
Name:ACOSTA, JENNIFER ANTUANETTE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANTUANETTE
Last Name:ACOSTA
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 1:11014 ISLAND BAY CIR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-6351
Mailing Address - Country:US
Mailing Address - Phone:812-814-8202
Mailing Address - Fax:
Practice Address - Street 1:419 S PARK AVE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1933
Practice Address - Country:US
Practice Address - Phone:305-780-9386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-323566106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty