Healthcare Provider Details

I. General information

NPI: 1710468137
Provider Name (Legal Business Name): MRS. JENNIFER L CORNETTE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

3697 LAKE EMMA RD
LAKE MARY FL
32746-6121
US

IV. Provider business mailing address

967 CHERRY BRANCH CT
LAKE MARY FL
32746-1944
US

V. Phone/Fax

Practice location:
  • Phone: 407-506-2999
  • Fax:
Mailing address:
  • Phone: 407-506-2999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA42934
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: