Provider Demographics
NPI:1790191195
Name:TAYLOR, JESSICA DEANDRA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DEANDRA
Last Name:TAYLOR
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 1:3469 SE COUNTY ROAD 337
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:FL
Mailing Address - Zip Code:32693-4581
Mailing Address - Country:US
Mailing Address - Phone:352-214-9474
Mailing Address - Fax:
Practice Address - Street 1:3469 SE COUNTY ROAD 337
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:FL
Practice Address - Zip Code:32693-4581
Practice Address - Country:US
Practice Address - Phone:352-214-9474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker