MEDICARE: MRS. TIFFANY JACQUES SLP

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	SZ4042	FL

General Provider Information

NPI Number	:	1366583510
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TIFFANY JACQUES SLP

Provider Business Mailing Address
First Line	:	5306 RABBIT RIDGE TRL
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32818-8782
Country	:	US
Telephone Number	:	407-616-8077
Fax Number	:

Provider Business Practice Location Address
First Line	:	5306 RABBIT RIDGE TRL
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32818-8782
Country	:	US
Telephone Number	:	407-616-8077
Fax Number	:

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

Provider Enumeration Date	:	02/09/2007
Last Update Date	:	09/04/2007

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