Provider Demographics
NPI:1063856144
Name:BERRIOS, JENNIFER RENAE (LMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENAE
Last Name:BERRIOS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 SW SANDY WAY
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-2082
Mailing Address - Country:US
Mailing Address - Phone:772-812-7734
Mailing Address - Fax:
Practice Address - Street 1:271 SW SANDY WAY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2082
Practice Address - Country:US
Practice Address - Phone:772-812-7734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-19
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA47543171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor