Provider Demographics
NPI:1104616812
Name:RIVERA, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RIVERA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15466 WOODBURY DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32234-3248
Mailing Address - Country:US
Mailing Address - Phone:904-408-9360
Mailing Address - Fax:
Practice Address - Street 1:15466 WOODBURY DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32234-3248
Practice Address - Country:US
Practice Address - Phone:904-408-9360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-07
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA93665225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist