Provider Demographics
NPI:1528735446
Name:AVELLAN, JENSON JOVAN
Entity type:Individual
Prefix:
First Name:JENSON
Middle Name:JOVAN
Last Name:AVELLAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6732 PETUNIA DR
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33023-4851
Mailing Address - Country:US
Mailing Address - Phone:954-945-6574
Mailing Address - Fax:
Practice Address - Street 1:6732 PETUNIA DR
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33023-4851
Practice Address - Country:US
Practice Address - Phone:954-945-6574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-27
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician