MEDICARE: JESSICA SULLIVAN

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	261QD1600X	Developmental Disabilities Clinic/Center		FL

General Provider Information

NPI Number	:	1891421186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA SULLIVAN

Provider Business Mailing Address
First Line	:	4813 BRISTOL BAY WAY APT 302
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33619-3662
Country	:	US
Telephone Number	:	813-562-8475
Fax Number	:

Provider Business Practice Location Address
First Line	:	4813 BRISTOL BAY WAY APT 302
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33619-3662
Country	:	US
Telephone Number	:	813-562-8475
Fax Number	:

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

Provider Enumeration Date	:	07/28/2022
Last Update Date	:	07/28/2022

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