Healthcare Provider Details

I. General information

NPI: 1790778934
Provider Name (Legal Business Name): JENNIFER S. LAND PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNY S. LAND PH.D.

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 10/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2602 NW 6TH ST STE A
GAINESVILLE FL
32609-2944
US

IV. Provider business mailing address

PO BOX 918025
ORLANDO FL
32891-8025
US

V. Phone/Fax

Practice location:
  • Phone: 352-392-4541
  • Fax: 352-392-7766
Mailing address:
  • Phone: 352-392-4541
  • Fax: 352-392-7766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY4855
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY0004855
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: