Provider Demographics
NPI:1861378267
Name:KATTAKAYAM, JAYA AJU
Entity type:Individual
Prefix:
First Name:JAYA
Middle Name:AJU
Last Name:KATTAKAYAM
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 1:510 DIAMOND RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-5048
Mailing Address - Country:US
Mailing Address - Phone:813-406-9366
Mailing Address - Fax:
Practice Address - Street 1:1723 S KINGS AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6220
Practice Address - Country:US
Practice Address - Phone:813-681-4413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11039253363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily