Provider Demographics
NPI:1225886328
Name:MESA MARTINEZ, JERLEN (RBT)
Entity type:Individual
Prefix:
First Name:JERLEN
Middle Name:
Last Name:MESA MARTINEZ
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 1:20583 SW 103RD AVE
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33189-3636
Mailing Address - Country:US
Mailing Address - Phone:813-859-1899
Mailing Address - Fax:
Practice Address - Street 1:10379 SW 186TH ST
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-6824
Practice Address - Country:US
Practice Address - Phone:786-250-5165
Practice Address - Fax:786-250-5158
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-338887106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician