Provider Demographics
NPI:1073131520
Name:SEAL, JESSICA L
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:SEAL
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 1:334 W ARM DR
Mailing Address - Street 2:
Mailing Address - City:WEWAHITCHKA
Mailing Address - State:FL
Mailing Address - Zip Code:32465-8715
Mailing Address - Country:US
Mailing Address - Phone:228-239-3779
Mailing Address - Fax:
Practice Address - Street 1:850 N TYNDALL PKWY
Practice Address - Street 2:
Practice Address - City:CALLAWAY
Practice Address - State:FL
Practice Address - Zip Code:32404-9407
Practice Address - Country:US
Practice Address - Phone:228-239-3779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-126908106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician