Provider Demographics
NPI:1619522505
Name:SANTOS HERNANDEZ, JENIELY
Entity Type:Individual
Prefix:
First Name:JENIELY
Middle Name:
Last Name:SANTOS HERNANDEZ
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 1:929 GILMORE AVE APT 139
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-8803
Mailing Address - Country:US
Mailing Address - Phone:939-244-3297
Mailing Address - Fax:
Practice Address - Street 1:929 GILMORE AVE APT 139
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-8803
Practice Address - Country:US
Practice Address - Phone:939-244-3297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health