Healthcare Provider Details

I. General information

NPI: 1235041757
Provider Name (Legal Business Name): JENNIFER LANDRY LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 ELM ST
NICEVILLE FL
32578-2018
US

IV. Provider business mailing address

207 BEACH DR APT C
DESTIN FL
32541-2491
US

V. Phone/Fax

Practice location:
  • Phone: 850-716-4481
  • Fax:
Mailing address:
  • Phone: 850-687-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA71103
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: