Provider Demographics
NPI:1043863111
Name:NODAL, JESSICA (LAT, ATC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:NODAL
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13560 CYPRESS GLEN LN UNIT 202
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33637-1116
Mailing Address - Country:US
Mailing Address - Phone:702-403-9658
Mailing Address - Fax:
Practice Address - Street 1:4202 E FOWLER AVE STOP ATH100
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620-8455
Practice Address - Country:US
Practice Address - Phone:702-403-9658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL56982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer