Healthcare Provider Details

I. General information

NPI: 1891945101
Provider Name (Legal Business Name): JENNIFER RUTH STOCKMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 09/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 INTERNATIONAL PKWY SUITE 2051
HEATHROW FL
32746-5303
US

IV. Provider business mailing address

708 SKY TREE CT
NEW SMYRNA BEACH FL
32168-6185
US

V. Phone/Fax

Practice location:
  • Phone: 800-798-6035
  • Fax:
Mailing address:
  • Phone: 386-214-5114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number10136
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: