Provider Demographics
NPI:1407457161
Name:MALLEK CAMPOS, JENNA GRACE
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:GRACE
Last Name:MALLEK CAMPOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:GRACE
Other - Last Name:MALLEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13626 PHOENIX DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-9338
Mailing Address - Country:US
Mailing Address - Phone:407-925-9104
Mailing Address - Fax:
Practice Address - Street 1:13626 PHOENIX DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-9338
Practice Address - Country:US
Practice Address - Phone:407-925-9104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-07
Last Update Date:2020-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health