Provider Demographics
NPI:1063215390
Name:PONCE, JESSICA M I
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:PONCE
Suffix:I
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15544 W COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-9556
Mailing Address - Country:US
Mailing Address - Phone:800-457-4573
Mailing Address - Fax:800-443-6422
Practice Address - Street 1:2601 SW 37TH AVE STE 904
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33133-2751
Practice Address - Country:US
Practice Address - Phone:800-457-4573
Practice Address - Fax:800-443-6422
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH25249101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health