Healthcare Provider Details

I. General information

NPI: 1982925103
Provider Name (Legal Business Name): JENNIFER LYNN DETTLOFF M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2010
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 E FOWLER AVE SUITE B
TAMPA FL
33617-2026
US

IV. Provider business mailing address

14275 MIDWAY RD SUITE 400
ADDISON TX
75001-3614
US

V. Phone/Fax

Practice location:
  • Phone: 813-972-7100
  • Fax: 813-972-8269
Mailing address:
  • Phone: 813-972-7100
  • Fax: 610-271-4245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number125058726
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME127025
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: