Provider Demographics
NPI:1700136223
Name:MATHENY, JENNA MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:MATHENY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-312-3475
Mailing Address - Fax:321-768-5090
Practice Address - Street 1:1223 GATEWAY DR STE 1B
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-312-3475
Practice Address - Fax:321-409-3685
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9269565363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01165529OtherFL RR MEDICARE
FLG0606YOtherFL MEDICARE