Audrey Petersen, CCC-SLP

Primary specialty

Speech-Language PathologistTaxonomy code 235Z00000X

License

SA15457 Issued in FL

Practice address

12276 San Jose Blvd Ste 508
Jacksonville, FL 32223-8618

Phone

(904) 886-3228

NPI assigned

Aug 24, 2016

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 1

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Speech and Occupational Specialists, LLC

  • Clinic/Center
  • Winter Garden, FL
  • NPI 1215288667

  Speech-Language Pathologist

  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1471996800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1632960000000",
    "number": "1336694892",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12276 SAN JOSE BLVD STE 508",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322238618",
            "telephone_number": "904-886-3228"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12276 SAN JOSE BLVD STE 508",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322238618",
            "telephone_number": "904-886-3228"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSEN",
        "first_name": "AUDREY",
        "credential": "CCC-SLP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2016-08-24",
        "last_updated": "2021-09-30",
        "certification_date": "2021-09-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "235Z00000X",
            "taxonomy_group": "",
            "desc": "Speech-Language Pathologist",
            "state": "FL",
            "license": "SZ7762",
            "primary": false
        },
        {
            "code": "235Z00000X",
            "taxonomy_group": "",
            "desc": "Speech-Language Pathologist",
            "state": "FL",
            "license": "SA15457",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "018756200",
            "state": "FL"
        }
    ],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "greatstridesrehab.com",
            "affiliation": "N",
            "address_1": "12276 San Jose Blvd Ste 508",
            "city": "Jacksonville",
            "state": "FL",
            "country_code": "US",
            "postal_code": "322238618",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Jessica Dwan Peters, MS, ATC, LAT, PES
• Josh C Peters
• Michelle Chen Peters, DPT
• Robert James Peters, DMD
• Anne M Petersen, PA
• Beyonce Petersen
• Courtney Petersen, MD
• John M Petersen, D.O
• Peterson Assisted Living Facility
• Cheyenne W Peterson-Gurak, COTA

• Speech-Language Pathologist in Jacksonville, FL
• Providers in Jacksonville, FL by specialty
• Speech-Language Pathologist in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 30, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.