Provider Demographics
NPI:1790923282
Name:SUMMERS, JEANETTE BOSELA (MS)
Entity Type:Individual
Prefix:MS
First Name:JEANETTE
Middle Name:BOSELA
Last Name:SUMMERS
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 1:4719 S FERNCREEK AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-7834
Mailing Address - Country:US
Mailing Address - Phone:407-341-0129
Mailing Address - Fax:
Practice Address - Street 1:4719 S FERNCREEK AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-7834
Practice Address - Country:US
Practice Address - Phone:407-341-0129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-22
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH-6839101YM0800X
FLIMT1660106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist