Provider Demographics
NPI:1205830692
Name:JESSEE, TIFFANY M (DO)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:M
Last Name:JESSEE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 PASADENA AVE S STE 2E
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:FL
Mailing Address - Zip Code:33707-4560
Mailing Address - Country:US
Mailing Address - Phone:727-289-7137
Mailing Address - Fax:727-498-6418
Practice Address - Street 1:1609 PASASENA AVE S
Practice Address - Street 2:SUITE 3M
Practice Address - City:SOUTH PASADENA
Practice Address - State:FL
Practice Address - Zip Code:33707
Practice Address - Country:US
Practice Address - Phone:727-289-7137
Practice Address - Fax:727-498-6418
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7737208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267547100Medicaid
FL267547100Medicaid
FL28044AMedicare ID - Type Unspecified