Provider Demographics
NPI:1215409156
Name:SHOOSHTARI, JEANNETTE CAZARES
Entity type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:CAZARES
Last Name:SHOOSHTARI
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 1:2423 S ORANGE AVE # 353
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-4543
Mailing Address - Country:US
Mailing Address - Phone:703-870-3880
Mailing Address - Fax:
Practice Address - Street 1:3660 WHEELER AVE STE A
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-6403
Practice Address - Country:US
Practice Address - Phone:703-870-3380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133002136103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30016807140002Medicaid