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General NPI Number Information
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NPI Number | 1770197865
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Entity Type | Individual
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Provider Name | JESSICA MAE SULLIVAN AU.D.
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Gender | Female
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Dates
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Enumeration Date | 09/04/2020
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Last Update Date | 09/04/2020
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Provider Practice Location Address
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Address Line | 2900 VETERANS WAY
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City | VIERA
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State | FL
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Zip | 32940-8007
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Country | US
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Telephone | 321-637-3788
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Fax |
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Provider Business Mailing Address
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Address Line | 407 SNOOK PL
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City | COCOA
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State | FL
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Zip | 32927-4757
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Country | US
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Telephone | 954-801-2663
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 231H00000X
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Taxonomy Name | Audiologist
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License Number | AUD004245
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License Number State | GA
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