Healthcare Provider Details

I. General information

NPI: 1710268107
Provider Name (Legal Business Name): JENNIFER A MCDANIEL LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2011
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15309 SUN DANCE LN
YOUNGSTOWN FL
32466-1846
US

IV. Provider business mailing address

15309 SUN DANCE LN
YOUNGSTOWN FL
32466-1846
US

V. Phone/Fax

Practice location:
  • Phone: 850-625-5640
  • Fax:
Mailing address:
  • Phone: 850-625-5640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA38198
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: