Provider Demographics
NPI:1144254137
Name:COMBS, JESSICA (BA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:COMBS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:RUNYON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:PO BOX 9478
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34206-9478
Mailing Address - Country:US
Mailing Address - Phone:941-782-4299
Mailing Address - Fax:941-782-4301
Practice Address - Street 1:379 6TH AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-8820
Practice Address - Country:US
Practice Address - Phone:941-782-4150
Practice Address - Fax:941-782-4104
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL758588800Medicaid