Provider Demographics
NPI:1740556398
Name:HERNANDEZ, JESELLIE (COTA)
Entity Type:Individual
Prefix:
First Name:JESELLIE
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9318 E COLONIAL DR
Mailing Address - Street 2:SUITE B3
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-4100
Mailing Address - Country:US
Mailing Address - Phone:407-281-3803
Mailing Address - Fax:407-249-8916
Practice Address - Street 1:9318 E COLONIAL DR
Practice Address - Street 2:SUITE B3
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-4100
Practice Address - Country:US
Practice Address - Phone:407-281-3803
Practice Address - Fax:407-249-8916
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11158224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOTA11158OtherLICENSE