Provider Demographics
NPI:1790778934
Name:LAND, JENNIFER S (PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:S
Last Name:LAND
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:S
Other - Last Name:LAND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-392-4541
Mailing Address - Fax:352-392-7766
Practice Address - Street 1:2602 NW 6TH ST
Practice Address - Street 2:STE A
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-2944
Practice Address - Country:US
Practice Address - Phone:352-392-4541
Practice Address - Fax:352-392-7766
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4855103T00000X
FLPY0004855103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
BK701ZMedicare PIN
FL59377Medicare ID - Type Unspecified