Provider Demographics
NPI:1952937492
Name:HENRY, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HENRY
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 1:3214 ACAPULCO DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-3701
Mailing Address - Country:US
Mailing Address - Phone:813-625-7461
Mailing Address - Fax:
Practice Address - Street 1:7940 VIA DELLAGIO WAY STE 142
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-5400
Practice Address - Country:US
Practice Address - Phone:407-745-4633
Practice Address - Fax:407-745-4635
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT20589225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist