Provider Demographics
NPI:1689403354
Name:WINNINGHAM, JAIDON
Entity type:Individual
Prefix:
First Name:JAIDON
Middle Name:
Last Name:WINNINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAIDON
Other - Middle Name:
Other - Last Name:ANGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15420 LIVINGSTON AVE APT 2112
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-3409
Mailing Address - Country:US
Mailing Address - Phone:813-784-5832
Mailing Address - Fax:
Practice Address - Street 1:13000 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4745
Practice Address - Country:US
Practice Address - Phone:813-972-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA22658235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist