Provider Demographics
NPI:1740474790
Name:COSBY, JENNIFER D (ITDS/ MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:D
Last Name:COSBY
Suffix:
Gender:F
Credentials:ITDS/ MA, CCC-SLP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:D
Other - Last Name:KILMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ITDS/ MA, CCC-SLP
Mailing Address - Street 1:844 BELLA VIDA BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-6719
Mailing Address - Country:US
Mailing Address - Phone:407-463-7875
Mailing Address - Fax:
Practice Address - Street 1:844 BELLA VIDA BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-6719
Practice Address - Country:US
Practice Address - Phone:407-463-7875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLSA10053235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000957900Medicaid