Healthcare Provider Details

I. General information

NPI: 1063672574
Provider Name (Legal Business Name): JENNIFER MUNOZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER E ROSADO

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 09/01/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 WEST, NC-54 SUITE 210
DURHAM NC
27707
US

IV. Provider business mailing address

1415 WEST, NC-54 BUILDING 200, SUITE 210
DURHAM NC
27707
US

V. Phone/Fax

Practice location:
  • Phone: 407-310-9269
  • Fax:
Mailing address:
  • Phone: 73-109-2694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberP7219
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number5930
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: