Provider Demographics
NPI:1679050413
Name:JANUSAS, JENNIFER REBECCA
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:REBECCA
Last Name:JANUSAS
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 1:14099 BELCHER RD S LOT 1086
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33771-4519
Mailing Address - Country:US
Mailing Address - Phone:386-361-1768
Mailing Address - Fax:
Practice Address - Street 1:29228 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-2101
Practice Address - Country:US
Practice Address - Phone:727-351-4191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-57585106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician