Healthcare Provider Details

I. General information

NPI: 1831649656
Provider Name (Legal Business Name): JEANNETTE SHORT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3238 S LECANTO HWY
LECANTO FL
34461-9025
US

IV. Provider business mailing address

1233 ALTOONA AVE
SPRING HILL FL
34609-6312
US

V. Phone/Fax

Practice location:
  • Phone: 352-291-5555
  • Fax:
Mailing address:
  • Phone: 352-340-6547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW 13836
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: