Healthcare Provider Details

I. General information

NPI: 1598521957
Provider Name (Legal Business Name): JENNIFER M LUCY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2024
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5711 NE 19TH AVE
FT LAUDERDALE FL
33308-2416
US

IV. Provider business mailing address

5711 NE 19TH AVE
FT LAUDERDALE FL
33308-2416
US

V. Phone/Fax

Practice location:
  • Phone: 703-994-2901
  • Fax:
Mailing address:
  • Phone: 703-994-2901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number11028839
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: