Provider Demographics
NPI:1417519083
Name:JENNISON, PORTIA SHERYLENE
Entity Type:Individual
Prefix:
First Name:PORTIA
Middle Name:SHERYLENE
Last Name:JENNISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CONFEDERATE POINT RD
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-8552
Mailing Address - Country:US
Mailing Address - Phone:386-538-1325
Mailing Address - Fax:
Practice Address - Street 1:110 CONFEDERATE POINT RD
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-8552
Practice Address - Country:US
Practice Address - Phone:386-538-1325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty