=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710672191
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JENICA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2023
-----------------------------------------------------
Last Update Date | 09/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1209 E 2ND ST
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32771-1413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-792-0900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1209 E 2ND ST
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32771-1413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-792-0900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JENNIFER ANNE VESTAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-923-9543
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------