Healthcare Provider Details

I. General information

NPI: 1700278785
Provider Name (Legal Business Name): JESSICA HATHAWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2015
Last Update Date: 10/14/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2979 PGA BLVD STE 200
PALM BEACH GARDENS FL
33410
US

IV. Provider business mailing address

1363 NE CROTON ST
JENSEN BEACH FL
34957-4875
US

V. Phone/Fax

Practice location:
  • Phone: 407-953-5924
  • Fax:
Mailing address:
  • Phone: 407-953-5924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: