Provider Demographics
NPI:1518367507
Name:HAUTZENROEDER, JESSICA FOX
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:FOX
Last Name:HAUTZENROEDER
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 1:1455 AZALEA AVE.
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707
Mailing Address - Country:US
Mailing Address - Phone:407-310-4119
Mailing Address - Fax:
Practice Address - Street 1:305 NORTH LAKEMONT AVE.
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792
Practice Address - Country:US
Practice Address - Phone:407-339-2225
Practice Address - Fax:407-339-2221
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA.319.35225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist