Healthcare Provider Details

I. General information

NPI: 1295062685
Provider Name (Legal Business Name): JENNIFER IRVINE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2009
Last Update Date: 11/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 TECH BLVD
TAMPA FL
33619-7865
US

IV. Provider business mailing address

1412 TECH BLVD
TAMPA FL
33619-7865
US

V. Phone/Fax

Practice location:
  • Phone: 813-635-9765
  • Fax: 813-635-9725
Mailing address:
  • Phone: 813-635-9765
  • Fax: 813-635-9725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH7500
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: