Provider Demographics
NPI:1770718462
Name:JESSICA M. BOOTH M.S.CCC-SLP & ASSOC. ,P.A.
Entity type:Organization
Organization Name:JESSICA M. BOOTH M.S.CCC-SLP & ASSOC. ,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:M S CCC-SLP
Authorized Official - Phone:954-319-7609
Mailing Address - Street 1:7782 N SOUTHWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-3810
Mailing Address - Country:US
Mailing Address - Phone:954-319-7609
Mailing Address - Fax:440-965-4303
Practice Address - Street 1:7782 N SOUTHWOOD CIR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-3810
Practice Address - Country:US
Practice Address - Phone:954-319-7609
Practice Address - Fax:440-965-4303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-25
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 8417235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1023108891OtherINDIV. NPI
FL890534700Medicaid