Provider Demographics
NPI:1578038881
Name:MONDRAGON, JENNY
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:MONDRAGON
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 1:15501 BRUCE B DOWNS BLVD APT 2411
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-1312
Mailing Address - Country:US
Mailing Address - Phone:954-907-3424
Mailing Address - Fax:
Practice Address - Street 1:517 DELTONA BLVD STE A
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-8016
Practice Address - Country:US
Practice Address - Phone:386-259-5413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist