Provider Demographics
NPI:1942500558
Name:MESA, JENNIFER LEE
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:LEE
Last Name:MESA
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 1:17906 SW 29TH ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33029-5155
Mailing Address - Country:US
Mailing Address - Phone:954-258-2560
Mailing Address - Fax:954-438-6539
Practice Address - Street 1:17906 SW 29TH ST
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33029-5155
Practice Address - Country:US
Practice Address - Phone:954-258-2560
Practice Address - Fax:954-438-6539
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-28
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ5130235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist