Healthcare Provider Details

I. General information

NPI: 1164705901
Provider Name (Legal Business Name): JENNY'S ASSISTED LIVING FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16116 TAMPA ST
LUTZ FL
33548-6125
US

IV. Provider business mailing address

16116 TAMPA ST
LUTZ FL
33548-6125
US

V. Phone/Fax

Practice location:
  • Phone: 813-210-0982
  • Fax:
Mailing address:
  • Phone: 813-210-0982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL11700
License Number StateFL

VIII. Authorized Official

Name: MRS. JENNY M SEGARRA
Title or Position: VICE-PRESIDENT/ADMINISTRATOR
Credential:
Phone: 813-210-0982