Provider Demographics
NPI:1710242524
Name:HALL, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HALL
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 1:2843 SW MILL CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-3196
Mailing Address - Country:US
Mailing Address - Phone:318-547-2456
Mailing Address - Fax:772-675-9100
Practice Address - Street 1:2843 SW MILL CREEK WAY
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990
Practice Address - Country:US
Practice Address - Phone:318-547-2456
Practice Address - Fax:318-547-2456
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-08
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-17-7942106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1111OtherXXX