Basic Information
Provider Information
NPI: 1780309864
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FERRER
FirstName: JESSICA
MiddleName: LYNN
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1824 COLTON DR
Address2:  
City: ORLANDO
State: FL
PostalCode: 328224618
CountryCode: US
TelephoneNumber: 3214371026
FaxNumber:  
Practice Location
Address1: 601 S LAKE DESTINY RD STE 350
Address2:  
City: MAITLAND
State: FL
PostalCode: 327517222
CountryCode: US
TelephoneNumber: 4076476555
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/11/2022
LastUpdateDate: 10/11/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 10/11/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000X  Y    

No ID Information.


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