Provider Demographics
NPI:1659673887
Name:PETRUCCI, JENNIFER LYNN (LMT)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LYNN
Last Name:PETRUCCI
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 1:4027 65TH PL E
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-7967
Mailing Address - Country:US
Mailing Address - Phone:941-224-2027
Mailing Address - Fax:
Practice Address - Street 1:4027 65TH PL E
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-7967
Practice Address - Country:US
Practice Address - Phone:941-224-2027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-19
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA41874225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist