=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093151722
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA CONAWAY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2013
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7758 WALLACE RD STE 6
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32819-7217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-372-8853
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 123
-----------------------------------------------------
City | GOTHA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34734-0123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-372-8853
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------