Healthcare Provider Details

I. General information

NPI: 1730832577
Provider Name (Legal Business Name): VANESSA DORADO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1493 NORTHLAKE DR
JACKSON MS
39211-2138
US

IV. Provider business mailing address

PO BOX 59083
JACKSON MS
39284-9083
US

V. Phone/Fax

Practice location:
  • Phone: 305-244-1531
  • Fax:
Mailing address:
  • Phone: 130-524-4153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: VANESSA DORADO
Title or Position: OWNER
Credential: MS, OTR/L
Phone: 305-244-1531