Provider Demographics
NPI:1023108891
Name:BOOTH, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BOOTH
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 1:5400 S UNIVERSITY DR STE 215A
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-5310
Mailing Address - Country:US
Mailing Address - Phone:954-319-7609
Mailing Address - Fax:954-265-7050
Practice Address - Street 1:5400 S UNIVERSITY DR STE 215A
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-5310
Practice Address - Country:US
Practice Address - Phone:954-319-7609
Practice Address - Fax:954-265-7050
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 8417235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115170000Medicaid
FL111269900Medicaid