Provider Demographics
NPI:1548582646
Name:VESTAL, JENNIFER ANNE (LMHC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ANNE
Last Name:VESTAL
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-1413
Mailing Address - Country:US
Mailing Address - Phone:407-792-0900
Mailing Address - Fax:
Practice Address - Street 1:1209 E 2ND ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1413
Practice Address - Country:US
Practice Address - Phone:407-792-0900
Practice Address - Fax:321-363-4835
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH12862101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001767100Medicaid