Healthcare Provider Details

I. General information

NPI: 1689186900
Provider Name (Legal Business Name): JENNA MACGILLIVRAY ROGERSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 04/05/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10129 CLEAR VISTA ST
ORLANDO FL
32832-7164
US

IV. Provider business mailing address

740 JAVA RD
COCOA BEACH FL
32931-3075
US

V. Phone/Fax

Practice location:
  • Phone: 833-663-6331
  • Fax:
Mailing address:
  • Phone: 407-761-4737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW18064
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: