Provider Demographics
NPI:1053762401
Name:VERGARA, JENNIFER DAWN
Entity type:Individual
Prefix:
First Name:JENNIFER DAWN
Middle Name:
Last Name:VERGARA
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 1:2527 EDGEWATER FALLS DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-2297
Mailing Address - Country:US
Mailing Address - Phone:561-319-6697
Mailing Address - Fax:
Practice Address - Street 1:5628 36TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1914
Practice Address - Country:US
Practice Address - Phone:727-424-1578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0167393106E00000X, 106E00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst