Provider Demographics
NPI:1861045684
Name:TANDLICH, JESSICA ANNE (MS)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:TANDLICH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10851 SW 68TH AVE
Mailing Address - Street 2:
Mailing Address - City:PINECREST
Mailing Address - State:FL
Mailing Address - Zip Code:33156-3921
Mailing Address - Country:US
Mailing Address - Phone:305-987-4716
Mailing Address - Fax:
Practice Address - Street 1:1855 S WRIGHT ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-3963
Practice Address - Country:US
Practice Address - Phone:303-982-9270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-21
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ9121235Z00000X
FLSA18402235Z00000X
COSLP.0005006235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist