Provider Demographics
NPI:1194443705
Name:RIVERA, JENNIFER D (SLPA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:D
Last Name:RIVERA
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N CENTRAL AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4439
Mailing Address - Country:US
Mailing Address - Phone:407-530-5063
Mailing Address - Fax:877-399-5578
Practice Address - Street 1:18115 N US HIGHWAY 41 STE 800
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-6475
Practice Address - Country:US
Practice Address - Phone:813-848-0341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225500000X, 222Q00000X
FLSI54632355S0801X
252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
No252Y00000XAgenciesEarly Intervention Provider Agency