MEDICARE: JESSICA N GRANDE PT, DPT, CSCS

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	225100000X	Physical Therapist	PT25095	FL

General Provider Information

NPI Number	:	1295931376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA N GRANDE PT, DPT, CSCS

Provider Business Mailing Address
First Line	:	16849 CEDAR RUN DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-6977
Country	:	US
Telephone Number	:	724-991-4718
Fax Number	:

Provider Business Practice Location Address
First Line	:	578 OCOEE COMMERCE PKWY
Second Line	:
City	:	OCOEE
State	:	FL
Zip	:	34761-4219
Country	:	US
Telephone Number	:	407-656-6639
Fax Number	:	407-656-0921

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

Provider Enumeration Date	:	06/25/2007
Last Update Date	:	01/27/2015

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