MEDICARE: CLEMENTINE SPEECH THERAPY LLC

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	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1093646440
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEMENTINE SPEECH THERAPY LLC

Provider Business Mailing Address
First Line	:	1911 BURLINGTON AVE N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33713-8030
Country	:	US
Telephone Number	:	757-636-0746
Fax Number	:

Provider Business Practice Location Address
First Line	:	1911 BURLINGTON AVE N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33713-8030
Country	:	US
Telephone Number	:	757-636-0746
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. AEMELIA LYNN JACKSON
Credential	:
Telephone Number	:	757-636-0746

Provider Enumeration Date	:	05/26/2026
Last Update Date	:	05/26/2026

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Directions to “CLEMENTINE SPEECH THERAPY LLC ” Practice Location

Language	Start Address	Practice Location

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