Provider Demographics
NPI:1457780637
Name:PACKING-EBUEN, JENNIFER (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:PACKING-EBUEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426W BRANDON BLVD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5002
Mailing Address - Country:US
Mailing Address - Phone:813-681-4444
Mailing Address - Fax:813-661-8763
Practice Address - Street 1:426W BRANDON BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5002
Practice Address - Country:US
Practice Address - Phone:813-681-4444
Practice Address - Fax:813-661-8763
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME118201207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine