MEDICARE: MRS. JAQUALINE FORT SLP-CFY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SZ5745	FL

General Provider Information

NPI Number	:	1043584295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JAQUALINE FORT SLP-CFY

Provider Business Mailing Address
First Line	:	2308 ECON CIR APT 183
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32817-2691
Country	:	US
Telephone Number	:	407-937-8664
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 SAVAGE CT STE 101
Second Line	:
City	:	LONGWOOD
State	:	FL
Zip	:	32750-4988
Country	:	US
Telephone Number	:	407-271-4911
Fax Number	:	407-264-8344

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2012
Last Update Date	:	03/06/2012

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