Healthcare Provider Details

I. General information

NPI: 1013467919
Provider Name (Legal Business Name): JENNIFER THIBODEAUX PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 GULF TO BAY BLVD STE 300
CLEARWATER FL
33759-4304
US

IV. Provider business mailing address

3000 GULF TO BAY BLVD STE 300
CLEARWATER FL
33759-4304
US

V. Phone/Fax

Practice location:
  • Phone: 727-222-5821
  • Fax:
Mailing address:
  • Phone: 727-610-2395
  • Fax: 727-933-0399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY9698
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: