Healthcare Provider Details

I. General information

NPI: 1629460001
Provider Name (Legal Business Name): JYOTHIS JOSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2015
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 RIDGEWOOD AVE
BRANDON FL
33510-4617
US

IV. Provider business mailing address

206 RIDGEWOOD AVE
BRANDON FL
33510-4617
US

V. Phone/Fax

Practice location:
  • Phone: 813-662-1060
  • Fax: 813-662-0530
Mailing address:
  • Phone: 813-662-1060
  • Fax: 813-662-0530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT15916
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: