Healthcare Provider Details

I. General information

NPI: 1801016324
Provider Name (Legal Business Name): JEANNETTE CORREDOR PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 04/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6442 COMMERCE PARK DR SUITE #1
FORT MYERS FL
33966-4723
US

IV. Provider business mailing address

6442 COMMERCE PARK DR SUITE 1
FORT MYERS FL
33966-4723
US

V. Phone/Fax

Practice location:
  • Phone: 239-768-6500
  • Fax: 239-768-6421
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY7717
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number016181-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: