Provider Demographics
NPI:1750513420
Name:COLEMAN, JESSIDRA
Entity type:Individual
Prefix:MISS
First Name:JESSIDRA
Middle Name:
Last Name:COLEMAN
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 1:17615 SW 97TH AVE
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-5636
Mailing Address - Country:US
Mailing Address - Phone:786-268-2611
Mailing Address - Fax:786-252-2421
Practice Address - Street 1:17615 SW 97TH AVE
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-5636
Practice Address - Country:US
Practice Address - Phone:786-268-2611
Practice Address - Fax:786-252-2421
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-14
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL762132900Medicaid