Healthcare Provider Details

I. General information

NPI: 1144143520
Provider Name (Legal Business Name): JENNIE BISSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIE LARY

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 PARKWOOD LN W
NICEVILLE FL
32578-8721
US

IV. Provider business mailing address

4500 PARKWOOD LN W
NICEVILLE FL
32578-8721
US

V. Phone/Fax

Practice location:
  • Phone: 316-617-9409
  • Fax:
Mailing address:
  • Phone: 316-617-9409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number27700
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: