Provider Demographics
NPI:1356646343
Name:SOUTHARD, JENNIFER DIANE (ND)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:DIANE
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:105 S RIVERSIDE DR
Mailing Address - Street 2:SUITE 131
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-4365
Mailing Address - Country:US
Mailing Address - Phone:321-409-0044
Mailing Address - Fax:321-409-0099
Practice Address - Street 1:105 S RIVERSIDE DR
Practice Address - Street 2:SUITE 131
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-4365
Practice Address - Country:US
Practice Address - Phone:321-409-0044
Practice Address - Fax:321-409-0099
Is Sole Proprietor?:No
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT099.0074287175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath