Provider Demographics
NPI:1487843637
Name:SMART, JANE BRADLEY (MS SLP)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:BRADLEY
Last Name:SMART
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:MONICA
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4202 E FOWLER AVE STOP PCD1017
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620
Practice Address - Country:US
Practice Address - Phone:813-974-9844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA9842235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100838000Medicaid
FLKG737OtherBLUE CROSS BLUE SHIELD