Provider Demographics
NPI:1043756208
Name:HINES, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 CORAL GLEN LOOP APT 208
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-0808
Mailing Address - Country:US
Mailing Address - Phone:305-799-3194
Mailing Address - Fax:
Practice Address - Street 1:624 CORAL GLEN LOOP APT 208
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-0808
Practice Address - Country:US
Practice Address - Phone:305-799-3194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator