Basic Information
| Provider Information | |||||||||
| NPI: | 1659832558 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMON | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 695141 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 332692141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7863617632 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10300 SW 72ND ST STE 114 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331733038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055085580 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2019 | ||||||||
| LastUpdateDate: | 07/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | FL | Y |
ID Information
| ID | Type | State | Issuer | Description | 019318600 | 05 | FL | MEDICAID |