Provider Demographics
NPI:1255864773
Name:LAYNE, JESSICA
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:LAYNE
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 1:741 W COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-7343
Mailing Address - Country:US
Mailing Address - Phone:407-843-1760
Mailing Address - Fax:407-843-1760
Practice Address - Street 1:4400 N HIGHWAY 19A
Practice Address - Street 2:UNIT 10
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2032
Practice Address - Country:US
Practice Address - Phone:407-843-1760
Practice Address - Fax:407-843-1767
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFL9220132Medicaid