Provider Demographics
NPI:1326481896
Name:SAN JUAN, JENNIFER KATHLEEN (LMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KATHLEEN
Last Name:SAN JUAN
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 1:3341 SW 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33023-5621
Mailing Address - Country:US
Mailing Address - Phone:954-309-6623
Mailing Address - Fax:
Practice Address - Street 1:3341 SW 40TH AVE
Practice Address - Street 2:
Practice Address - City:WEST PARK
Practice Address - State:FL
Practice Address - Zip Code:33023-5621
Practice Address - Country:US
Practice Address - Phone:954-309-6623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-15
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA68146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist