Healthcare Provider Details

I. General information

NPI: 1104579929
Provider Name (Legal Business Name): JENNIFER SLOBODA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 CARSON OAKS LN
SANTA ROSA BEACH FL
32459-7159
US

IV. Provider business mailing address

436 CARSON OAKS LN
SANTA ROSA BEACH FL
32459-7159
US

V. Phone/Fax

Practice location:
  • Phone: 630-337-0990
  • Fax:
Mailing address:
  • Phone: 630-337-0990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAPRN11012861
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: