Provider Demographics
NPI:1710570817
Name:JEROME, KASSANDRA MARCELLA (PTA)
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:MARCELLA
Last Name:JEROME
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2519 CHAPALA DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-3447
Mailing Address - Country:US
Mailing Address - Phone:321-284-7591
Mailing Address - Fax:
Practice Address - Street 1:830 29TH ST, ORLANDO, FL 32805
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:32805
Practice Address - Country:US
Practice Address - Phone:407-843-3230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30494225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant