Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker |
NPI | 1003170390 |
---|---|
Provider Name | Mr. Jesse Thomas Rivera |
First Address | Tampa, FL 33610-4350 |
Second Address | Tampa, FL 33610-4350 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/07/2012 |
Last Update Date | 02/07/2012 |