Provider Demographics
NPI:1275901035
Name:HART, JENNESSA (MSW)
Entity Type:Individual
Prefix:MS
First Name:JENNESSA
Middle Name:
Last Name:HART
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 LISENBY AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-2910
Mailing Address - Country:US
Mailing Address - Phone:850-763-7102
Mailing Address - Fax:
Practice Address - Street 1:7402 MCELVEY RD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32408-7606
Practice Address - Country:US
Practice Address - Phone:850-249-0433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075436605Medicaid