Provider Demographics
NPI:1346273612
Name:JENNETTE, JACQUELINE FAY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:FAY
Last Name:JENNETTE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 PINETREE DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:INDIAN HARBOUR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-4444
Mailing Address - Country:US
Mailing Address - Phone:321-777-5163
Mailing Address - Fax:321-777-6242
Practice Address - Street 1:1300 PINETREE DR
Practice Address - Street 2:SUITE 4
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-4444
Practice Address - Country:US
Practice Address - Phone:321-777-5163
Practice Address - Fax:321-777-6242
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3690103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75912Medicare ID - Type UnspecifiedMEDICARE ID