Provider Demographics
NPI:1255068805
Name:BENIBANONDE, JORDAN (MED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BENIBANONDE
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2902 BRUCKEN RD
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-5610
Mailing Address - Country:US
Mailing Address - Phone:770-654-0279
Mailing Address - Fax:
Practice Address - Street 1:2902 BRUCKEN RD
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-5610
Practice Address - Country:US
Practice Address - Phone:770-654-0279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16518235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty