Provider Demographics
NPI:1215150420
Name:MARVIN, JENNIFER NIKOLE KENDRA (LMHC)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:NIKOLE KENDRA
Last Name:MARVIN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4726 FLORENCE ST
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-5540
Mailing Address - Country:US
Mailing Address - Phone:407-929-6251
Mailing Address - Fax:407-788-0362
Practice Address - Street 1:2400 S RIDGEWOOD AVE STE 17
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-3073
Practice Address - Country:US
Practice Address - Phone:407-929-6251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH5186101Y00000X, 101YA0400X, 101YP2500X, 104100000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004240900Medicaid
FL076933900Medicaid