Provider Demographics
NPI:1851639207
Name:FUENTES PEREZ, JENNIFER (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:FUENTES PEREZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6421 N FLORIDA AVE
Mailing Address - Street 2:D-557
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604
Mailing Address - Country:US
Mailing Address - Phone:843-304-1431
Mailing Address - Fax:
Practice Address - Street 1:5305 MALPASO CREEK DR
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-4881
Practice Address - Country:US
Practice Address - Phone:843-304-1431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-18
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY12114103TC0700X
PR004555103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC405127Medicaid