Healthcare Provider Details

I. General information

NPI: 1306773320
Provider Name (Legal Business Name): JENA NICOLE LCSW PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1522 MAGNOLIA MANOR DR LOT K
GULF BREEZE FL
32563-5906
US

IV. Provider business mailing address

PO BOX 281
GULF BREEZE FL
32562-0281
US

V. Phone/Fax

Practice location:
  • Phone: 850-631-0431
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JENA NICOLE INGLEBY
Title or Position: OWNER
Credential: LCSW
Phone: 850-631-0431