Provider Demographics
NPI:1013723287
Name:LAND, JENNIFER MARIE (LMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:LAND
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 WINNEBAGO AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-1156
Mailing Address - Country:US
Mailing Address - Phone:805-305-6147
Mailing Address - Fax:
Practice Address - Street 1:1465 WINNEBAGO AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-1156
Practice Address - Country:US
Practice Address - Phone:805-305-6147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL100005225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist