Provider Demographics
NPI:1467964585
Name:WIDNER, JENNIFER JO (LMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JO
Last Name:WIDNER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6260 66TH ST N
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781-5024
Mailing Address - Country:US
Mailing Address - Phone:727-420-0093
Mailing Address - Fax:
Practice Address - Street 1:6260 66TH ST N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-5024
Practice Address - Country:US
Practice Address - Phone:727-420-0093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA24417225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty