Provider Demographics
NPI:1952951733
Name:JESSICADAVISCEO, LLC
Entity Type:Organization
Organization Name:JESSICADAVISCEO, LLC
Other - Org Name:PASSIONATE CHAMPION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:ALEXANDRA
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-877-0328
Mailing Address - Street 1:2550 PALM BAY RD NE STE 106
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-3565
Mailing Address - Country:US
Mailing Address - Phone:321-877-0328
Mailing Address - Fax:321-978-0288
Practice Address - Street 1:307 N GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-6222
Practice Address - Country:US
Practice Address - Phone:321-557-8979
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-13
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1952951733OtherN/A