Provider Demographics
NPI:1205482346
Name:PEDRAZA, JESSICA LEE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:PEDRAZA
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 1:613 LA COSTA ST
Mailing Address - Street 2:
Mailing Address - City:MINNEOLA
Mailing Address - State:FL
Mailing Address - Zip Code:34715-5676
Mailing Address - Country:US
Mailing Address - Phone:407-427-6640
Mailing Address - Fax:
Practice Address - Street 1:1050 US HIGHWAY 27 STE 9
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34714-7508
Practice Address - Country:US
Practice Address - Phone:352-394-0573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18699101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health