Healthcare Provider Details

I. General information

NPI: 1568691541
Provider Name (Legal Business Name): JENNIFER COLBERT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2009
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11337 LELAND GROVES DR
RIVERVIEW FL
33579-2442
US

IV. Provider business mailing address

6210 GREENLEAF LN
TAMPA FL
33617-1722
US

V. Phone/Fax

Practice location:
  • Phone: 813-360-3608
  • Fax:
Mailing address:
  • Phone: 937-681-7055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW9382
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: