Provider Demographics
NPI:1861019093
Name:TAYLOR, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
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 1:3543 SEMINOLE LN
Mailing Address - Street 2:
Mailing Address - City:BONIFAY
Mailing Address - State:FL
Mailing Address - Zip Code:32425-5817
Mailing Address - Country:US
Mailing Address - Phone:850-849-0389
Mailing Address - Fax:
Practice Address - Street 1:1083 SANDERS AVE
Practice Address - Street 2:
Practice Address - City:GRACEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32440-1854
Practice Address - Country:US
Practice Address - Phone:850-263-4447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-04
Last Update Date:2020-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA14277235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist