Basic Information
| Provider Information | |||||||||
| NPI: | 1760803316 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZIELSKE | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | M.A.,M.A., BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 FAIRWAY DRIVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | DEERFIELD BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334413521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888809270 | ||||||||
| FaxNumber: | 9543420273 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 COLONIAL CENTER PARKWAY | ||||||||
| Address2: | STE 100N | ||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546037885 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2013 | ||||||||
| LastUpdateDate: | 01/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 222Q00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist | 103K00000X | 1-15-20766 | GA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | XJBH83047816 | 01 | BLUE CROSS BLUE SHIELD | OTHER |