Provider Demographics
NPI:1730752528
Name:VENTURA, JISSELL ATHABEIRA
Entity type:Individual
Prefix:
First Name:JISSELL
Middle Name:ATHABEIRA
Last Name:VENTURA
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 1:11457 CRESCENT PINES BLVD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-7864
Mailing Address - Country:US
Mailing Address - Phone:347-867-3351
Mailing Address - Fax:
Practice Address - Street 1:6 N EUSTIS ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-3408
Practice Address - Country:US
Practice Address - Phone:321-276-5054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist