Healthcare Provider Details

I. General information

NPI: 1457802621
Provider Name (Legal Business Name): JADELL PATRICIO MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 10/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 TECH BLVD
TAMPA FL
33619-7865
US

IV. Provider business mailing address

3160 GRAND PAVILION DR UNIT 104
TAMPA FL
33613-3720
US

V. Phone/Fax

Practice location:
  • Phone: 727-593-0003
  • Fax:
Mailing address:
  • Phone: 954-598-5334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP362430919580
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: