Provider Demographics
NPI:1992097976
Name:MARDER, JESSICA SHIRLEY
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SHIRLEY
Last Name:MARDER
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 1:4887 NEW BROAD ST
Mailing Address - Street 2:APT 2013
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-6645
Mailing Address - Country:US
Mailing Address - Phone:727-735-3586
Mailing Address - Fax:
Practice Address - Street 1:4887 NEW BROAD ST
Practice Address - Street 2:APT 2013
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32814-6645
Practice Address - Country:US
Practice Address - Phone:727-735-3586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health