Provider Demographics
NPI:1164894887
Name:ESTRADA, JESSICA (PT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ESTRADA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 EAST BLOOMINGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511
Mailing Address - Country:US
Mailing Address - Phone:813-681-1627
Mailing Address - Fax:813-684-1356
Practice Address - Street 1:134 EAST BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511
Practice Address - Country:US
Practice Address - Phone:813-681-1627
Practice Address - Fax:813-684-1356
Is Sole Proprietor?:No
Enumeration Date:2015-10-21
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30569225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist