Provider Demographics
NPI:1174124978
Name:MARQUEZ, JELENNY
Entity type:Individual
Prefix:MRS
First Name:JELENNY
Middle Name:
Last Name:MARQUEZ
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 1:5285 NW SOUTH DELWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-2762
Mailing Address - Country:US
Mailing Address - Phone:305-904-0343
Mailing Address - Fax:
Practice Address - Street 1:529 SE PALM BEACH RD STE 103
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2477
Practice Address - Country:US
Practice Address - Phone:772-261-8517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB580550103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst