Healthcare Provider Details

I. General information

NPI: 1861019093
Provider Name (Legal Business Name): JENNA TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2020
Last Update Date: 07/04/2020
Certification Date: 07/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1083 SANDERS AVE
GRACEVILLE FL
32440-1854
US

IV. Provider business mailing address

3543 SEMINOLE LN
BONIFAY FL
32425-5817
US

V. Phone/Fax

Practice location:
  • Phone: 850-263-4447
  • Fax:
Mailing address:
  • Phone: 850-849-0389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA14277
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: