Basic Information
| Provider Information | |||||||||
| NPI: | 1215439633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORDERO | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 N REO ST | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336091061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133742070 | ||||||||
| FaxNumber: | 8133370937 | ||||||||
| Practice Location | |||||||||
| Address1: | 1121 DRUID RD E APT 812 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337564060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542987207 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2018 | ||||||||
| LastUpdateDate: | 01/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2355S0801X | SI-4635 | FL | N | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant | 222Q00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
ID Information
| ID | Type | State | Issuer | Description | 222 | 05 | FL | MEDICAID |