Provider Demographics
NPI:1215683669
Name:GAITAN, JESENIA
Entity type:Individual
Prefix:
First Name:JESENIA
Middle Name:
Last Name:GAITAN
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 1:191 SW PALM DR APT 306
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1901
Mailing Address - Country:US
Mailing Address - Phone:772-224-1624
Mailing Address - Fax:
Practice Address - Street 1:191 SW PALM DR APT 306
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1901
Practice Address - Country:US
Practice Address - Phone:772-224-1624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-24
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty