Provider Demographics
NPI:1740967454
Name:CARVAJAL, JESSICA VICTORIA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:VICTORIA
Last Name:CARVAJAL
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 1:15746 SW 146TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-6730
Mailing Address - Country:US
Mailing Address - Phone:786-512-2057
Mailing Address - Fax:
Practice Address - Street 1:12485 SW 137TH AVE STE 301
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4219
Practice Address - Country:US
Practice Address - Phone:786-512-2057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-04
Last Update Date:2023-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ11365235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist