Provider Demographics
NPI:1093024713
Name:OSORIO, JENNIFER R (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:OSORIO
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11741 SW 110TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-3927
Mailing Address - Country:US
Mailing Address - Phone:305-733-3405
Mailing Address - Fax:
Practice Address - Street 1:12494 SW 127TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-6597
Practice Address - Country:US
Practice Address - Phone:305-733-3405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2017-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA11047235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002675000Medicaid