Provider Demographics
NPI:1093361990
Name:TERRELL, JESSICA HILDA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:HILDA
Last Name:TERRELL
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:PO BOX 412
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:FL
Mailing Address - Zip Code:32663-0412
Mailing Address - Country:US
Mailing Address - Phone:352-622-7038
Mailing Address - Fax:
Practice Address - Street 1:11600 NW 140TH PL
Practice Address - Street 2:
Practice Address - City:REDDICK
Practice Address - State:FL
Practice Address - Zip Code:32686
Practice Address - Country:US
Practice Address - Phone:352-622-7038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL235893385HR2065X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child