Provider Demographics
NPI:1376841312
Name:BRAVO, JESSICA N (BSW)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:N
Last Name:BRAVO
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6410 KAHANA WAY
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34241-5525
Mailing Address - Country:US
Mailing Address - Phone:941-861-2900
Mailing Address - Fax:
Practice Address - Street 1:2200 RINGLING BLVD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34237-6102
Practice Address - Country:US
Practice Address - Phone:941-861-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-28
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00034785 00Medicaid