Provider Demographics
NPI:1053855452
Name:ATLANTIC SPEECH THERAPY
Entity Type:Organization
Organization Name:ATLANTIC SPEECH THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:OTTO
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:904-652-5408
Mailing Address - Street 1:11512 LAKE MEAD AVE
Mailing Address - Street 2:SUITE 604
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9680
Mailing Address - Country:US
Mailing Address - Phone:904-652-5408
Mailing Address - Fax:877-652-5052
Practice Address - Street 1:145 HILDEN ROAD #113
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-5139
Practice Address - Country:US
Practice Address - Phone:904-652-5408
Practice Address - Fax:877-652-5052
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATLANTIC SPEECH THERAPY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-05
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 11834235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty