Provider Demographics
NPI:1124768122
Name:SUMMERALL, JESSECA
Entity type:Individual
Prefix:
First Name:JESSECA
Middle Name:
Last Name:SUMMERALL
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 1:2302 LAKE LENA BLVD APT B
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33823-3132
Mailing Address - Country:US
Mailing Address - Phone:863-595-8045
Mailing Address - Fax:
Practice Address - Street 1:150 AVENUE B SE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3037
Practice Address - Country:US
Practice Address - Phone:863-944-0841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician