Provider Demographics
NPI:1235630849
Name:WILLISON, JESSICA A (LM, CPM)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:A
Last Name:WILLISON
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:A
Other - Last Name:SPALDING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2830 PLAZA TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-2816
Mailing Address - Country:US
Mailing Address - Phone:407-717-4704
Mailing Address - Fax:
Practice Address - Street 1:2750 TAYLOR AVE STE A19
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-4474
Practice Address - Country:US
Practice Address - Phone:407-717-4704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL359176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL359OtherFLORIDA DEPARTMENT OF HEALTH