Provider Demographics
NPI:1548771470
Name:MACK, JEANETTE (LMT)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:MACK
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 1:110 E REYNOLDS ST STE 300
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-3361
Mailing Address - Country:US
Mailing Address - Phone:813-659-4600
Mailing Address - Fax:
Practice Address - Street 1:110 E REYNOLDS ST STE 300
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-3361
Practice Address - Country:US
Practice Address - Phone:813-659-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA87367225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty