Provider Demographics
NPI:1376762559
Name:DEFAZIO, JENNA MICHAL (LMT LICENSED MASSAGE)
Entity Type:Individual
Prefix:MS
First Name:JENNA
Middle Name:MICHAL
Last Name:DEFAZIO
Suffix:
Gender:F
Credentials:LMT LICENSED MASSAGE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 N HOLLYBROOK LAKE DRIVE
Mailing Address - Street 2:#303
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025
Mailing Address - Country:US
Mailing Address - Phone:814-860-1900
Mailing Address - Fax:
Practice Address - Street 1:570 OCEAN DR
Practice Address - Street 2:HOLISTIC MASSAGE AND WELLNESS CLINICS #501
Practice Address - City:JUNO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408
Practice Address - Country:US
Practice Address - Phone:954-491-2225
Practice Address - Fax:954-491-6862
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL48182OtherMA #