Provider Demographics
NPI:1316224421
Name:DELUISA, JENNIFER C (DOM)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:C
Last Name:DELUISA
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:MCDERMOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DOM
Mailing Address - Street 1:15919 29TH ST E
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:FL
Mailing Address - Zip Code:34219-1854
Mailing Address - Country:US
Mailing Address - Phone:907-202-5577
Mailing Address - Fax:907-865-2433
Practice Address - Street 1:15919 29TH ST E
Practice Address - Street 2:
Practice Address - City:PARRISH
Practice Address - State:FL
Practice Address - Zip Code:34219-1854
Practice Address - Country:US
Practice Address - Phone:907-202-5577
Practice Address - Fax:907-865-2433
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1067171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist