Provider Demographics
NPI:1316645112
Name:PUENTES, JENNIFER DIAZ
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIAZ
Last Name:PUENTES
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 1:1065 W 76TH ST APT 126
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-3926
Mailing Address - Country:US
Mailing Address - Phone:786-694-9801
Mailing Address - Fax:
Practice Address - Street 1:1065 W 76TH ST APT 126
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-3926
Practice Address - Country:US
Practice Address - Phone:786-694-9801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-257775106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician