Provider Demographics
NPI:1114752466
Name:REBECK, JENNA LAUREN (APRN)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:LAUREN
Last Name:REBECK
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 1:2434 STRAWBERRY TER
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34286-3923
Mailing Address - Country:US
Mailing Address - Phone:941-301-9317
Mailing Address - Fax:
Practice Address - Street 1:1931 TAMIAMI TRL STE 4-6
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-2181
Practice Address - Country:US
Practice Address - Phone:941-888-0560
Practice Address - Fax:844-388-6186
Is Sole Proprietor?:No
Enumeration Date:2024-09-05
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1103632363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily