Provider Demographics
NPI:1578855698
Name:GILLETTE, JENNIFER M
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:M
Last Name:GILLETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:GILLETTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:1500 SE 13TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2212
Mailing Address - Country:US
Mailing Address - Phone:954-257-0711
Mailing Address - Fax:
Practice Address - Street 1:1500 SE 13TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2212
Practice Address - Country:US
Practice Address - Phone:954-257-0711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-08
Last Update Date:2011-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 8276103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist