Provider Demographics
NPI:1124683842
Name:MODESTE, JENNY SABINA
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:SABINA
Last Name:MODESTE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SABINA
Other - Middle Name:MODESTE
Other - Last Name:MALDONADO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4126 23RD AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-3356
Mailing Address - Country:US
Mailing Address - Phone:908-456-5465
Mailing Address - Fax:
Practice Address - Street 1:235 31ST ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-1000
Practice Address - Country:US
Practice Address - Phone:908-456-5465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL82911225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty