Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106S00000X | Behavior Technician |
NPI | 1003322645 |
---|---|
Provider Name | Michele Jezek |
First Address | Monument, CO 80132-9125 |
Second Address | Monument, CO 80132-9125 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/12/2017 |
Last Update Date | 19/12/2017 |