Provider Demographics
NPI:1811907678
Name:STEWART, JENNA S (MS, LMT)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:S
Last Name:STEWART
Suffix:
Gender:F
Credentials:MS, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 SARNO RD STE 3
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-4909
Mailing Address - Country:US
Mailing Address - Phone:321-253-8088
Mailing Address - Fax:321-253-0212
Practice Address - Street 1:1751 SARNO RD STE 3
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4909
Practice Address - Country:US
Practice Address - Phone:321-253-8088
Practice Address - Fax:321-253-0212
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA22024225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist