MEDICARE: MISS JESSENIA VAZQUEZ MSW

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	1041C0700X	Clinical Social Worker	20084	PR
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	20084	PR

General Provider Information

NPI Number	:	1134567555
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JESSENIA VAZQUEZ MSW

Provider Business Mailing Address
First Line	:	3035 66TH AVE N LOT 17
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33702-6267
Country	:	US
Telephone Number	:	727-251-6111
Fax Number	:

Provider Business Practice Location Address
First Line	:	5501 W WATERS AVE STE 406
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33634-1229
Country	:	US
Telephone Number	:	813-881-1000
Fax Number	:

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

Provider Enumeration Date	:	06/07/2013
Last Update Date	:	01/14/2015

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