Provider Demographics
NPI:1295088573
Name:HERRON, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HERRON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 CRESTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-4808
Mailing Address - Country:US
Mailing Address - Phone:386-852-4144
Mailing Address - Fax:
Practice Address - Street 1:259 BILL FRANCE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1316
Practice Address - Country:US
Practice Address - Phone:386-852-4144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator