Provider Demographics
NPI:1225621659
Name:STARK, JENNY LEE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:LEE
Last Name:STARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:LEE
Other - Last Name:PECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 CENTERVILLE RD STE 600
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4661
Mailing Address - Country:US
Mailing Address - Phone:317-225-7652
Mailing Address - Fax:
Practice Address - Street 1:1401 CENTERVILLE RD STE 600
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4661
Practice Address - Country:US
Practice Address - Phone:850-878-8121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-17
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11011658363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily