Provider Demographics
NPI:1558182626
Name:LOUIS, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LOUIS
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 1:1240 NW 155TH LN APT 107
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-6309
Mailing Address - Country:US
Mailing Address - Phone:305-497-7419
Mailing Address - Fax:561-516-8183
Practice Address - Street 1:4801 S UNIVERSITY DR STE 130
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-3832
Practice Address - Country:US
Practice Address - Phone:954-592-8659
Practice Address - Fax:561-516-8183
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-22
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-378489106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician