MEDICARE: JENNIFER M CORDERO PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	21772	FL

General Provider Information

NPI Number	:	1083283543
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER M CORDERO PTA

Provider Business Mailing Address
First Line	:	4274 SW RAGEN ST
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-7255
Country	:	US
Telephone Number	:	772-323-6623
Fax Number	:

Provider Business Practice Location Address
First Line	:	4274 SW RAGEN ST
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-7255
Country	:	US
Telephone Number	:	772-323-6623
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2021
Last Update Date	:	06/21/2021

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