Provider Demographics
NPI:1689944084
Name:POLAK, JENNIFER LYNN
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:POLAK
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 1:911 30TH CT
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-5040
Mailing Address - Country:US
Mailing Address - Phone:561-839-0930
Mailing Address - Fax:
Practice Address - Street 1:1025 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5386
Practice Address - Country:US
Practice Address - Phone:772-335-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS46644183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist