Provider Demographics
NPI:1740953991
Name:BALK, JENNIFER (MA MM)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BALK
Suffix:
Gender:F
Credentials:MA MM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5155 S WASHINGTON AVE # 104
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-7300
Mailing Address - Country:US
Mailing Address - Phone:321-361-8791
Mailing Address - Fax:
Practice Address - Street 1:5155 S WASHINGTON AVE # 104
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-7300
Practice Address - Country:US
Practice Address - Phone:321-361-8791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-25
Last Update Date:2021-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA85659225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist