Healthcare Provider Details

I. General information

NPI: 1508539826
Provider Name (Legal Business Name): JENNIFER ANN SERBACK PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 WILLIS AVE
DAYTONA BEACH FL
32114-2810
US

IV. Provider business mailing address

150 MAGNOLIA AVE
DAYTONA BEACH FL
32114-4304
US

V. Phone/Fax

Practice location:
  • Phone: 800-539-4228
  • Fax:
Mailing address:
  • Phone: 800-539-4228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11041109
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: