Provider Demographics
NPI:1720583230
Name:TOLES, JENNIFER BIANCA (MS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BIANCA
Last Name:TOLES
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17429 NEW CROSS CIR
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-4916
Mailing Address - Country:US
Mailing Address - Phone:181-353-8520
Mailing Address - Fax:
Practice Address - Street 1:17429 NEW CROSS CIR
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547
Practice Address - Country:US
Practice Address - Phone:813-538-5201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA00108805101YP2500X
103TC1900X, 1041C0700X, 174400000X
4235090171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator