Healthcare Provider Details

I. General information

NPI: 1497346506
Provider Name (Legal Business Name): JESSICA MARIE CANTU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 BURNS AVE
LAKE WALES FL
33853-3335
US

IV. Provider business mailing address

706 LAKE CUMMINGS BLVD
LAKE ALFRED FL
33850-2644
US

V. Phone/Fax

Practice location:
  • Phone: 863-679-3338
  • Fax:
Mailing address:
  • Phone: 787-901-8104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: