Provider Demographics
NPI:1760750632
Name:LIGHTFOOT, JENNIFER EVANS (LMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:EVANS
Last Name:LIGHTFOOT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:EVENS
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:411 NORTH MCDONALD AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32742
Mailing Address - Country:US
Mailing Address - Phone:386-682-7300
Mailing Address - Fax:
Practice Address - Street 1:411 NORTH MCDONALD AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32742
Practice Address - Country:US
Practice Address - Phone:386-682-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA9027174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist