Provider Demographics
NPI:1447892633
Name:ANDERSON, JAIMIE PAYNE
Entity type:Individual
Prefix:
First Name:JAIMIE
Middle Name:PAYNE
Last Name:ANDERSON
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:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:813-974-4325
Practice Address - Street 1:2950 CLEVELAND CLINIC BLVD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3625
Practice Address - Country:US
Practice Address - Phone:954-659-5786
Practice Address - Fax:954-659-5787
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA17255235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY911WOtherBLUE CROSS BLUE SHIELD
FL110446000Medicaid