Provider Demographics
NPI:1437421179
Name:PACKARD, JENNY VANESSA
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:VANESSA
Last Name:PACKARD
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 1:7941 NW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-8000
Mailing Address - Country:US
Mailing Address - Phone:305-263-6363
Mailing Address - Fax:305-263-6323
Practice Address - Street 1:7941 NW 2ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-8000
Practice Address - Country:US
Practice Address - Phone:305-263-6363
Practice Address - Fax:305-263-6323
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9178261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care