Provider Demographics
NPI:1730957788
Name:EXPOSITO ORTIZ, JORGE ANTONIO
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:ANTONIO
Last Name:EXPOSITO ORTIZ
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 1:3746 METRO PKWY APT 937
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-7419
Mailing Address - Country:US
Mailing Address - Phone:239-228-0929
Mailing Address - Fax:
Practice Address - Street 1:3746 METRO PKWY APT 937
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-7419
Practice Address - Country:US
Practice Address - Phone:239-228-0929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-308558106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician