Healthcare Provider Details

I. General information

NPI: 1619919594
Provider Name (Legal Business Name): JENNIFER LYNN SULLIVAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 12/24/2020
Certification Date: 12/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8937 W COLONIAL DR
OCOEE FL
34761-6918
US

IV. Provider business mailing address

2344 EH POUNDS DR
OCOEE FL
34761-8601
US

V. Phone/Fax

Practice location:
  • Phone: 407-628-1584
  • Fax:
Mailing address:
  • Phone: 407-628-1584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW4760
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: