Provider Demographics
NPI:1285084475
Name:SALAS ALFONSO, JENNIE
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:SALAS ALFONSO
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 1:9021 SW 156TH ST
Mailing Address - Street 2:APT C-224
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-1984
Mailing Address - Country:US
Mailing Address - Phone:786-231-7916
Mailing Address - Fax:
Practice Address - Street 1:9021 SW 156TH ST
Practice Address - Street 2:APT C-224
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157
Practice Address - Country:US
Practice Address - Phone:786-231-7916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-17
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-20-41420103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst