Provider Demographics
NPI:1710334008
Name:PROVENZA, JEANETTE I
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:PROVENZA
Suffix:I
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 1:2006 FISHERMENS BND
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-2355
Mailing Address - Country:US
Mailing Address - Phone:727-415-3260
Mailing Address - Fax:
Practice Address - Street 1:1515 MICHELIN CT
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-7533
Practice Address - Country:US
Practice Address - Phone:813-949-3904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health