MEDICARE: JESSICA E EVANS CCC-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	SA7704	FL

General Provider Information

NPI Number	:	1659435964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA E EVANS CCC-SLP

Provider Business Mailing Address
First Line	:	2539 S BAYSHORE DR APT 114
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33133-4732
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2801 PONCE DE LEON BLVD
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33134-6924
Country	:	US
Telephone Number	:	305-448-7101
Fax Number	:

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

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	07/08/2007

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Directions to “ JESSICA E EVANS CCC-SLP” Practice Location

Language	Start Address	Practice Location

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