Provider Demographics
NPI:1316809429
Name:JAIME FERNANDEZ, LAIRA
Entity type:Individual
Prefix:
First Name:LAIRA
Middle Name:
Last Name:JAIME FERNANDEZ
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 1:4711 BALSAM DR
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-5601
Mailing Address - Country:US
Mailing Address - Phone:813-841-4899
Mailing Address - Fax:
Practice Address - Street 1:6601 MEMORIAL HWY STE 107
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-4501
Practice Address - Country:US
Practice Address - Phone:813-480-0415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-26
Last Update Date:2025-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-25-85985103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst